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 have any questions concerning mental health issues, give me a call here.

>> PBS Fort Wayne by dialing in the Fort Wayne area (969) 27 two zero or if you're calling any place else coast to coast you may dial toll free at 866- (969) 27 two zero now on a fairly regular basis I am 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 a via the Internet at matters of the mind all one word at WFA a dog that's matters of the mind at work and I'll start tonight's program with a question I recently received.

>> It reads Dear Dr. Fauver, how much should question the judgment of our physicians?

I know they went to medical school but how can we tell that they are right?

Well, we're always seeking truth and you have a right to question your physician.

>> But here's the perspective.

You are the patient.

You're the one who's going to carry out the directions and as physicians we typically understand that we might make suggestions we might actually adamantly try to state our our opinion about different directions.

>> You should go but you are ultimately the one responsible for your health so you have a right to ask questions now you don't want to be like the annoying individual in high school that just ask question after question after question not really expecting an answer or wanting an answer but just wanting to annoy other people.

>> You don't want to do that with your physician.

Ask realistic questions and what we should do as physicians is always well question the validity of what we're prescribing and what we're recommending and we should do so with measurable outcomes.

We should always understand that we might not be on the right track right now throughout history in medicine there have been people who made a lot of assumptions about the truth of what they were recommending and they were wrong.

I mean over 200 years ago it wasn't common practice to wash your hands following a surgical procedure and it was thought that would just be a hindrance and then it was found with email Semmelweis that he recommended and noticed that more women were dying in the post of obstetrics wards after they had a baby when the clinicians were not washing their hands b when they were going in between patients he made that recommendation and he was ostracized as a physician for making that recommendation.

>> So we should always question what we believe is valid, always seeking truth but the way you seek truth was with observational sciences you have a hypothesis and that hypothesis is should be measurable.

So you test what you think is true and you measure it and you validate it always being a bit skeptical that maybe you're not on the right track.

And as physicians we need to consider that.

So when we make recommendations to you as a patient you're the one ultimately responsible but for instance I will often see patients who insist that they want to take herbs and they want to use marijuana on a regular basis as a means of treating their anxiety.

I'm going to state my opinion on that based on what I understand in science.

But you ultimately will be the one to determine what you want to do.

>> And with that being said in questioning your physician's judgment in questioning the validity of what you're being recommended to do by your physician, you have a right to do that.

>> But don't simply question the physician's judgment as a means of asking more questions.

Try to understand what your condition is so you can better your overall well-being.

So that's the ultimate ultimate goal to try to find the truth and to be able to measure what kind of hypotheses you might have about a particular situation.

>> I'm always very skeptical about scientists who are insisting that they know how things are or how things were and they know the truth for sure when they haven't really been able to measure it adequately.

So I think we should always stay a bit skeptic.

We should all stay a little bit skeptical about what we think is the truth and always keep our mind open to other possibilities.

>> Thanks for your question.

Let's go to our first caller.

Hello Lewis.

Welcome to Matters Mind Lewis.

>> You want to know if having the covid virus makes mental conditions worse?

>> It might.

Lewis there are some conditions we call them long hallers.

These are people who've had the covid virus and they corvus the virus does get to the brain and it's basically can get to the brain where the the smelling nerves come out the olfactory nerves up here and for some reason it goes right there and when covid goes to that part of the brain you can lose your sense of smell while you have the covid virus infesting you but you can have some difficulty later on with fatigue and difficulty with concentration.

>> We've seen this with other viruses as well.

So it's not unique covid we've seen it with other viruses where you'll have lingering fatigue, lingering difficulty, the concentration it's it's quite rare that we actually hear about it, Lewis but it does happen in some cases and in those situations there's always studies and we're always trying to understand how to better to treat could people have been treated more aggressively while they had Kova to prevent that?

Are there risk factors for who might have some lingering symptoms for some people versus others we just don't know to this date we are treating some people in my practice with difficulty with depression and poor concentration where they specifically have difficulty processing information so their speed of processing seems to be dampened somewhat.

It's seen with depression but we have seen it with some patients with covid is very rare so it doesn't happen very often but it can happen.

We've seen this for instance with Lyme disease people who have Lyme disease which is brought on by deer ticks, they've been bitten by a deer tick and those people will often have fatigue and difficulty with concentration in my practice that's a similar type of phenomenon.

What I've seen with some people with covid who are the so-called covid long haulers we've heard about other people having body aches and other physical problems but from a psychiatric or mental disturbance standpoint it's more difficulty with fatigue and difficulty with processing speed and concentration.

Lewis, thanks for your call.

Let's go to our next email.

Our next e-mail reads Dear Doctor Father, my sister in law just lost her mother to cancer and is having a hard time coping with this.

She has been going to therapy but it doesn't seem to be helping.

>> Are there any medicinal treatments that could ease this grief?

Complicated grief is where you have symptoms of major depression where you have difficulty enjoying things you become more socially reclusive, you have trouble with concentration.

You can't do the kind of things you usually do day by day and eventually it does significantly impact the sleep and it's a cascade of different symptoms that emerge.

>> It's it's normal to have grief the with the loss of a loved one and that grief can go on for weeks if not months and if you lose a child it can go on for a much longer time than that.

But when you get complicated grief that's where you have difficulties major depressive symptoms day by day for at least two weeks such as difficulty with appetite, sleep, concentration, motivation and it gives you specific difficulty getting things done day by day.

You don't take care of yourself with personal hygiene.

You can't go to work and go to school.

You can't be around other people.

>> That's where it becomes a clinical depression and nowadays we tend to treat this complicated grief as we would a clinical depression.

So we'll use antidepressant medications.

There's 16 oral antidepressants medications that have come out since nineteen eighty seven.

We might use medications very briefly for sleep such as Ambien or Lunesta no more than a couple of weeks in those cases but we might use other medications for sleep such as Doxa and Gabapentin or Trazodone if you're having ongoing difficulty with sleep as you can imagine lack of sleep will significantly impair your functioning.

We hear about this all the time.

A lot of people have experienced it.

When you miss a few nights of sleep it affects not only your energy level but it will significantly affect your judgment, your ability to think to process information.

>> It's like your computer's just gotten more dulled in your brain where you just can't process information adequately if you lack sleep.

>> So I always tell people about three fourths of what we do in psychiatry will be to Ralph about try to get people help with sleep because if we can get you better sleep it makes a dramatic difference in your overall functioning and we see this not uncommonly with people who are going through complicated grief night by night by night.

They're dwelling ruminating about the loss of the loved one and they can't get that off their minds.

They might even have intense dreams or even nightmares about the loss of a loved one and it can turn into post-traumatic stress, post-traumatic stress basically is where you have a traumatic stressor.

It's been devastating for you and it causes you to be jumpy.

You're hyper alert.

You're always expecting something bad to happen.

Thereby you can't sleep and you have nightmares and you start to avoid other people because other people and memories might provoke that thought to to return.

So post-traumatic stress is something that can occur following complicated grief therapy with grief counseling can be great for people who are going through complicated prolonged grief.

But sometimes we will use medications just to help the chemistry of the brain get back on track because when you get significantly depressed the left front part of the brain up here which is the reasoning, judgment and concentration part of the brain that's the part of the brain that becomes dampened in its activity.

So we're trying to fire up that front part of the brain to allow you to have better judgment if the front part of brain is not working adequately.

Unfortunately, the anxiety, anger and irritability part of the brain down here in the amygdala kind of takes over.

So you hear sometimes about people saying their emotions are taking over.

>> They're thinking well from a neurobiology standpoint that's exactly what's happening.

The emotions are in this area here and they can take over the front part of your brain which is the rational reasoning and judgment part of your brain.

So in psychiatry we're always trying to figure out at least from a medicinal standpoint how to allow this front part of the brain to work more normally and once the front part of the brain is working normally you can augment any effective medication with psychotherapy or counseling because psychotherapy or counseling will be working on the reasoning part of the brain to try to help you objectively and rationally think through your problems as opposed to emotionally reacting.

>> So with grief from a neurobiological standpoint, yeah, it's basically a condition where your opiate receptors are somewhat dampened now we don't have good opiate medications now for depression we might have some over the next five years or so because not only are we talking about treating depression with medications that enhance dopamine, norepinephrine and serotonin now we're talking about this other chemical quite a bit called glutamate.

You can enhance the glutamate system with medications like ketamine or the nasal spray is ketamine also known as bravado?

You can affect glutamate with Lamotrigine or Lamictal which is a medication we commonly used to help people deal with stress more effectively.

But now we're starting to talk about ways to help the opiate system without being addictive and it gets tricky.

There's three different types of opiate receptors there.

There's the MMU receptors, Delta receptors and kapa receptors and we need to be able to affect the cell receptors in an appropriate appropriate way to help with depression but yet not causing addiction and going along with addiction with opiate receptors can cause the can be the respiratory depression where you basically stop breathing as you go higher and higher on those doses.

So there are different ways that you can manipulate those opiate receptors without causing addiction, without causing suppression of the breathing.

And that's what's getting studied fairly extensively right now as a means of helping with depression, specifically grieving in a different way than traditional antidepressants will do.

Now the nice thing about the opiate receptor system is it'll give you a sense of bliss and it'll give you a feeling of happiness and contentment.

Well, that's exactly why people will abuse opiates and unfortunately within narcotics and opiates or that are on the market right now and the ones that are abused on the street, that's what people are trying to achieve.

They're trying to achieve happiness and bliss through the use of the narcotic.

But unfortunately narcotics to get the same effect you have to go higher and higher and higher on the dosage and then next thing you know you get to the ceiling dosage where it shuts down your breathing and that's how people die of narcotic overdose.

But they initially have a sense of contentment and bliss and it's unlike any other medication they'll ever experience and when people get a medication like Percocet or Norco or Oxycodone, those kind of medications when they get these medications for a broken arm or for a sprained ankle, next thing you know they like how they feel and they like the feeling of contentment and the feeling of bliss, fullness and happiness they get from the narcotic and then they take off with using them not for the pain anymore but they start using them for their mood and when they start using these medications for the moods that's where we get into trouble and that's where the opiate crisis has emerged over the course of time.

>> Thanks for your email question.

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

Our next e-mail question reads Dear Doctor Favre, I have tardive dyskinesia.

Are there any are there any treatments tardive dyskinesia basically as a condition where you're blocking dopamine receptors and it's related to antipsychotic medications that it can be used for mood stabilization as well and the antipsychotic medications basically are blocking these receptors called dopamine type two receptors.

When you block dopamine type two receptors over the course of time for some people they actually out.

They kind of out more dopamine receptors in the middle of the brain and this brain called the basal ganglia and when that happens they get a dopamine hypersensitivity where they become twitchy in some cases they can have hard blinking, they can have mouth movements, they can have their tongue flickering.

Sometimes they'll have shoulder and trunk movements and that's called tardive dyskinesia.

It is basically because the movement center of your brain has become over sensitized to dopamine because there's too many dopamine receptors that are there.

So how do you get around that?

Well, the first thing you want to do is see if you can back off of the antipsychotic or the dopamine blocker to allow those dopamine receptors to maybe decrease in number we call down regulation but decrease in number to get back on normal track.

People with tardive dyskinesia are more likely to have it if they have a mood disturbance and we do have a couple of medications that are really good for tardive dyskinesia.

One is called Ingres, one is called a stereo and a stereo is a medication.

>> It came out second but Ingres that came out first both of these medications in Krasa and Estero tend to have this effect on the brain where they will decrease dopamine release by enhancing its breakdown in the firing neuron and what they are as they're called VMD two inhibitors that means vesicular monoamine transporter type two which type 2s and the brain was type one is more on the gut.

What they're doing basically is enhancing the breakdown of dopamine in the firing neurons such that there's less dopamine floating around to overstimulate these excessive but it out receptors.

So that's how stato and that's how Ingres it will work for people.

So with that being said how do they vm out to inhibitors work basically if you think about the ancient cities who had the walls all around them to get into the city to get safe you got through the gate and then you have the gate closed and you got inside the safety of the walls of the city.

Dopamine has to get in these vesicles and if you think of the vesicles as being like walled cities for dopamine once it gets back into the firing neuron and it's to get transported back into the vesicle and that's like the walled city if you block off the city gate and dopamine has to stay outside that vesicle, it gets exposed to enzymes, break it down.

So that's how the DEMATTE two inhibitors work.

They basically block off the wall the vesicle because of the dope making it back inside that little bubble of the vesicle inside the firing neuron.

It's safe from enzymatic breakdown if it's outside that visit vesicular wall it tends to get broken down and decreases in its volume so you have less dopamine that way.

Now what's nice is that when people have less dopamine in the basal ganglia system it doesn't seem to affect their mood that much.

I thought it would when I first heard about these mechanisms but it doesn't because apparently the the vesicles aren't so prominent in other parts of the brain but they are very prominent in the basal ganglia and again that middle part of the brain is the part of the brain that gives us smooth movements and if that's disturbed you can have these jerky movements, you can have twitches and tics and all these things that go along with tardive dyskinesia.

So the first thing you want to do tardive dyskinesia is try to get off the antipsychotic medication.

The second thing you want to do is consider Ingres Austro as a medication to be able to medicinally help with that type of condition.

And the third thing to always consider is maybe have the condition in which you're being treated treated with the medication.

It doesn't necessarily affect dopamine.

For instance, if you have a mood disturbance where you don't necessarily specifically need a dopamine blocker, maybe there's other options out there such as an anti epileptic medication or lithium or other means of treating him.

People are at a higher risk for tardive dyskinesia if No one they had really bad stiffness when they first started the medication.

So if you ever had really bad stiffness or you had difficulty with tremulousness, if you had dystonia which is the stiffness that is a that gives you a higher risk later of tardive dyskinesia as you get older you're at a higher risk for tardive dyskinesia.

>> So getting older puts people at a higher risk having an antipsychotic medication prescribed for you when you have more of a mood disorder and you don't have schizophrenia that apparently puts at a higher risk and it's thought that underlying diabetes puts you at a higher risk for tardive dyskinesia.

We do genetic testing now on these dopamine type two receptors and some people will have a mutation of doping type receptors that also seems to put you at a higher risk for tardive dyskinesia.

So we consider all those type of things as we're getting people these antipsychotic medications especially for mood disturbances to to stabilize their overall moods.

>> Thanks for your email question.

Let's go to our next caller.

Hello Gary.

Welcome to Matters of Mind.

>> Well, Gary, you had mentioned you just just lost your wife a month ago.

I'm so sorry to hear that, Gary.

You had mentioned that your grief is getting pretty bad.

You don't know if you should go on a medication or should you just talk to a counselor you'd like some guidance on that, Gary.

>> Here's what it comes down to.

Your grief is going to stay with you for a while.

Yes, it does.

fade.

The important thing for you to do is try to stay physically active, watch your diet right now because people tend to eat a lot of junk and carbohydrates when they're grieving.

>> They just don't care.

You want to try to do the best you can to stay around people maintain a lot of social support scary and because that's really helpful it will be normal for you to reminisce about your wife.

You're going to be thinking a lot about her.

But Gary, when it gets to the point where you have a hard time getting out of the house when you have a hard time sleeping night by night by night lack of sleep is a significant predictor for somebody having depression and anxiety.

We often hear about this cascade, Gary, where people start they have anxiety or they're grieving.

They start to lose sleep with the loss of sleep comes depression.

So we're always trying to reverse that cascade and get the wheel going the other direction where they can at least well get their sleep back and once they sleep returns normal that will help out quite a bit.

You can certainly talk to a counselor as a means of maintaining your perspective on where you are now and where you're going because you're going to be going through another chapter in your life at this point with the loss of your wife and your life is going to be very, very different and you're aware of that and you're dealing with that at this point.

But you take medications where the grief has been complicated, where it's causing to have difficulty on a day to day basis getting things done that you want to get done.

So when you can't go to work, you can't go to school, you can't be around people and it's affecting your physical health as it often can.

>> That's where it can be a problem.

Gary, it's no surprise that spouses who lose their loved ones are at a much higher risk of having a cardiac arrhythmia within six months after losing their spouse and it's called the Broken-Hearted Syndrome as you can imagine.

>> It's it really comes down to the heart going into an arrhythmia, into an abnormal beating because the heart becomes overly sensitive and you're overly stressed out.

That's very common within the first six months after the loss of a loved one.

And Gary often hear about that for people who have significantly lost sleep, they have a lot of anxiety and those kind of problems do cascade over the course of time.

So talk to your primary care clinician initially about how you're doing at this point to see if you could benefit from any medication for depression or for sleep now for sleep usually it's a short term type of treatment no matter than a few weeks of treatment is for most people for depression if it's the first depression you've ever experienced to this degree which is housing units just lingering on, it's a really affecting your day to day functioning.

You would be on the antidepressant medication typically for about a year and after a year you look at the pros and cons of staying on it or going off of it.

But many people who have lost a loved one will notice that month by month by month they can recover, they can get their lives back but you're going to have some spontaneous unprovoked crying spells just out of the blue occasionally that's perfectly normal.

It's where it starts to interfere with your life and you can't get things done.

That's where it becomes problematic.

Gary, I wish you the best.

Thanks for calling in.

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

Our next e-mail question reads Dear Dr. Fauver, I was recently diagnosed with depression.

Which antidepressant is the best?

The best and depressant for you is the one that's going to work for you and everybody's a little bit different.

We do a genetic testing nowadays to try to figure out at what dosage and which type of medication might work best for people.

As I mentioned earlier, there's 16 newer and a presence that came out since nineteen eighty seven Prozac being the first that came out of the newer oral antidepressants that we have these other antidepressants that have come out and they don't work a little bit differently.

Many of them do work particularly on serotonin, dopamine and norepinephrine but they do so a little bit different way.

Some of them will affect various receptors and that's why for some people they'll do better on one antidepressant versus another.

>> About one out of three people are really good genetic fits for the serotonin medications.

The serotonin medications are widely prescribed Prozac, Zoloft, Lexapro, Celexa and Paxil widely widely prescribed.

>> But two out of three people aren't real good fits for those medications genetically as we test people genetically and we look back on their histories, we find that that's often confirmed a second factor you can always consider is that there's these little Isawa enzymes.

These are enzymes in the liver, the breakdown medications and people have different propensities for breaking down some medications quickly and other medications not so quickly.

And if you down medications quickly, you need to take those medications at higher dosages to get the same effect.

If you break down medications slowly, certain medications slowly you would need a lower dosage of those medications.

So it's important to try to get that understanding from a genetic standpoint.

Some people will find that they will need a particular vitamin supplement called methyl folate because they just don't break down folic acid very well and folic acid is vitamin B nine .

So it is A B vitamin and the only way to know if you are prone to breaking down folic acid adequately would be to get genetic testing specifically looking at methylene tetra hydro folate redacts far methylene tetrahedral folate reduc tastes and looking at six seventy seven and twelve ninety eight those the two enzymes that the two genes we look at to see how well you break down folic acid we look at the combination of those particular genetic makeups and determine if you need the special form of folic acid that way called Elmsford Folate which is the active byproduct.

So that would be a factor with genetic testing.

Most importantly, you know, if you have difficulty depression, it's always important to figure out what kind of depression it is.

Is it straight major depression where you have pretty much straight depression to have bipolar depression where you're having highs and lows?

Is it situational depression where you only get depressed in certain situations and it's very brief we're going to treat those kind of conditions entirely differently.

>> So it's very important to have a good diagnostic assessment there and it's also very important to understand the medical reasons why you might have depression such as sleep apnea, low thyroid and low iron and even diabetes for that matter.

Thanks for your call.

Unfortunately I'm out of time this evening.

If you have any questions concerning mental health issues that I can answer on the air, you may write me a via the Internet at matters of the mind all one word WSW Edgar 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.

Have good evening.

>> Good night