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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 25th year or 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 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 866- (969) 27 two zero now on a fairly regular basis we are broadcasting live every Monday night from our spectacular PBS Fort Wayne Teleflex which lies 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 WFYI Big that's matters of the mind at WFYI and I'll start tonight's program with some questions I recently received.

The first one reads Dear Dr. Fauver, what do you foresee occurring in the treatment of mental health issues in the next few years?

>> Any new medication types expected for the past 30 years we've had very similar medications coming out for depression such that back in nineteen eighty seven Prozac was the first of a flurry of newer and a presence to come out Prozac and work any better than the older antidepressants.

But it was just more tolerable and Prozac was more selective in what it did.

>> And following Prozac we've had about sixteen newer oral antidepressants come on the market over the past twenty five years or so and what's changed as time has evolved is that the medications that have been coming on the market for depression have mainly focused on serotonin, norepinephrine and dopamine and now we're having more of a focus on different types of chemicals like glutamate.

We're having focus on Sigma one receptors that were unheard of before 20 years ago and sigma one receptors will modulate inflammation because now we're looking at depression as being a condition for many people will involve inflammation.

>> So that's why it's a whole body experience.

That's why when some people get depressed they feel achy all over.

They feel like they can't concentrate.

They're tired, they don't have any motivation and it feels very much like they have the flu from a physiological standpoint.

Yeah, it's very much similar to the flu when you have depression in some cases.

>> So we're looking at depression outside the box from just serotonin, norepinephrine and dopamine and that's how we've been looking at it for over twenty five years now we're looking at it with a variety of different medications in the treatment of schizophrenia and bipolar disorder.

These are conditions where we're avoiding a lot of the metabolic problems that were present twenty years go used to be twenty years ago if somebody was on an antipsychotic medication for schizophrenia or bipolar disorder it was inedible.

>> They were going to have some significant side effects whether they be increased appetite, weight gain their weight circumferences would increase.

They could have significant problems in various other areas and now we're taking a closer look at that.

We're being more proactive in psychiatry to try to determine if people are having problems with diabetes sooner rather than later whereas before only when people had symptoms of diabetes such as excessive thirst, excessive appetite fatigue, poor concentration then we checked blood sugars.

Well, by that time if you're having symptoms of diabetes, chances are that plane's already left the gate.

I mean you've had those high blood sugars coming on for a while.

So now we know that if you're going to have diabetes Type two Type two diabetes, you're going to have those kind of problems with higher insulin, higher triglycerides.

These metabolic issues are going to evolve for sometimes nine to 12 years even before you get the high blood sugars.

So we're trying to be more proactive in psychiatry is not just thinking from the neck up but actually thinking about the whole body and I think you're going to see that significantly be impacted over the next few years.

We're not going to be just talking about somebody's mood, somebody's emotional state, somebody's ability to tolerate stress.

We're going to be talking about their overall physical health such as body aches and we'll talk more about gastrointestinal problems, cardiac issues, metabolic issues which can impact mental health as well.

And one of my favorite conditions to always monitor will be sleep apnea.

It's something we didn't assess twenty years go now we routinely assess it for people who are especially having difficulty with snoring and feeling tired they can't concentrate with sleep apnea is where basically you're not getting adequate airflow to the lungs that decreases oxygen to the brain and the next day you're going to be feeling really tired and depressed and you can't think and we find that for a lot of people sleep apnea treatment can have a dramatic impact on their overall mental health .

It's something that we should have been exploring twenty years ago but it's just not getting recognized in psychiatry as being a big factor for many, many patients.

>> We've always looked at endocrine issues to some degree such is thyroid conditions and diabetes which I mentioned.

But I think we'll be stepping up our assessment those as time goes on we'll going to probably be using fewer and fewer benzodiazepines as time goes on.

Those have been popular medications over the past my goodness.

Thirty five years when I came out of pharmacy school in nineteen seventy nine and I was first a pharmacist the number one medication of all medication on the market for any condition was Valium.

Valium goes by the generic name Diazepam and in nineteen seventy nine Valium was the number one of all medications prescribed and it was thought that Valium Valium helped people feel calm and decrease their likelihood to get upset about things they kind of felt chilled out but over the course of the years, you know, we've had other medications come out related to Valium like out of an Klonopin Xanax.

These are medications that are benzodiazepines and the effect is part of the brain called the amygdala right up here and that's the anxiety and anger and rage volume control and it will calm that down and that sounds kind of it's kind of nice because when you calm down the anxiety volume control you decrease the thinking part of the brain and sometimes it'll decrease the likelihood for the front part of the brain to overreact in certain situations so you can suppress the likelihood that you're going to overreact in situations.

But the problem with benzodiazepines is no one can make you not care and they just make you not care.

And secondly, as we get older they can affect especially the memory and concentration any age the benzodiazepines such as Xanax and Klonopin and Valium can decrease the speed of process.

So it's like having a computer speed in your brain that gets slowed down.

We all get frustrated when we're on our computer.

It's kind of slow and we want to go from one screen to another and it's kind of stalling for a few milliseconds.

Well now we realize that with the benzodiazepines they actually slow the processing speed of the brain.

So we're trying to get away from those more and more and trying to deal with anxiety in other ways.

So we're trying to get away from Xanax, Valium, Klonopin, Ativan, the medications that have been around for a long time.

We're using them sparingly for some people is for some people that's the only way they can get on a flight and be able to fly someplace and we but we want to use them sparingly.

>> We don't like to see people using those kind of medications day by day by day and I think on the next few years you're going to be hearing about alternatives to the treatment of depression, especially as we hear about more research with CBD and hopefully to get more research about cannabis or THC in terms of its detrimental effects to try to understand how better we can treat people who are dependent on cannabis or marijuana.

>> Thanks for your email.

Let's go to our first caller.

Hello.

Be welcome to Matters of Mind.

Hi and my name is Bea.

Yeah so I had a question I am a person who has both bipolar as well as an you know, other mental health issues that go with it because you know there's never only one but I also fibromyalgia and I feel like my doctor right now doesn't really talk about my my chronic pain issues and I'm wondering about how to talk to my doctor about you, my mental health , how how my mental health affects my physical health and how my physical affects my .

>> Physical health affects my mental health .

You explained it very well right there because you can't separate the two and this has been an argument that I have had with a lot of people in the mental health field for the past 30 some years.

>> You can't separate what the brain is doing and what the rest of the body is doing and as you very all know with fibromyalgia you're tired, you're achy, you have this point tenderness all over.

>> You feel worse typically in the morning and you feel like the Tin Man on Wizard of Oz and you need your old squirrel squirted on your joints and just it's a terrible feeling.

>> Women are are eight times more likely than men to experience fibromyalgia and people didn't understand it so well in the past.

>> But over the past 15 years or so there's been better understanding about fibromyalgia.

>> There's a particular chemical in the blood that gets to the brain.

It's called substance is in PIJ substance P is increased in the brain in various areas when people have fibromyalgia symptoms particularly in the sensory part of the brain on the side.

>> So we know it's a real physical physiological condition.

When you have fibromyalgia you're more prone to having this higher amount of substance p does that mean you need to get a spinal tap to confirm it?

No, but we just understand that with symptoms of fibromyalgia you'll have certain physical type of events happening now with fibromyalgia.

There's a couple of things that happen at the actual nerves themselves.

Number one, the nerves have an itchy trigger finger and the nerves nerves have an itchy trigger finger especially for calcium influx.

And when calcium is in fluxing excessively your nerves will fire too much and it makes you have more pain.

>> So what do you do to treat fibromyalgia?

>> A couple of things you can use gabapentin also known as Neurontin and Lyrica also known as Pregabalin.

>> These are medications that are anti seizure medications that will stabilize that little calcium channel and decrease the itchy trigger finger of the firing of the nerves themselves.

>> So that's one way we treat fibromyalgia from a medicinal standpoint.

A second way will be using a medication by name of Dellucci or Cymbalta, another medication known as FETs Zema.

>> Sometimes prestige is used Savola is a medication.

These medications basically are affecting norepinephrine and to some degree serotonin and to various degrees and if you increase the transmission serotonin and norepinephrine you can get a breaking of the pain coming up the spinal cord.

>> So in other words you don't get as much pain perceived coming up the spinal cord so to medication treatments will often consider with fibromyalgia treatment will be the use of Lyrica or Neurontin and will use medications that increase serotonin and norepinephrine like Cymbalta Fed CEMA Scevola.

>> These are medications that can break the pain.

Coming up the spinal cord now you mentioned you have bipolar disorder.

Many people with bipolar disorder will have trouble sleeping and as you can imagine, fibromyalgia does give you difficulty sleeping because you're feeling achy at nighttime and when you turn over it wakes you up and it's it's one of the theories behind fibromyalgia is that people with fibromyalgia don't sleep deeply and if you don't sleep deeply, you're more prone to having more pain the next day that goes for all of us but especially people with fibromyalgia.

>> So you have to take all these considerations into account keeping in mind that if you have bipolar disorder you have to be careful using Cymbalta fjtes Zema Savala these are medications that increase norepinephrine and serotonin and they can make moodiness worse for bipolar disorder.

There's different types of bipolar disorder that's very important.

You get that assessed and I understand kind of bipolar disorder you have if you have one week of mania or more where you don't need to sleep then you're more impulsive and you're talking really fast.

>> You're going topic to topic the topic of doing things the ordinarily wouldn't do one week or more of mania gives you bipolar disorder type one for bipolar disorder type one you want to use the antidepressant medications that are also increasing serotonin and norepinephrine very cautiously because you can make moodiness worse if you have bipolar disorder type two where you have four to six days of little little highs hypomania but they're not causing you a lot of trouble but you predominantly have the big lows for two weeks or more with major depression that's bipolar disorder type two with a mood stabilizer you could use an antidepressant medication that increases serotonin and norepinephrine in either case whether you had bipolar disorder type one or bipolar disorder type two , you could use gabapentin also known as Neurontin or Pregabalin also known as Lyrica.

>> Those are medications that would be safe and either way.

But if you have five Maloja and A bipolar history B you want to be able to make sure that you get adequate sleep on a day to day basis.

>> Adequate sleep number one will help your mood stability.

But number two , it'll help with fibromyalgia symptoms.

Secondly, make sure your thyroid gets checked at least once a year.

Women especially with low thyroid will typically have a lot of difficulty with worsening in their mood stability if they have bipolar disorder, they'll feel more tired, they'll feel more depressed, they'll have more difficulty concentration.

So you want to be a stickler for making sure that thyroid test is getting carefully assessed about once a year for and a lot of cases if you have fibromyalgia you want to be able to exercise and move around to a agree that you can tolerate.

Now that's a very fine line because some people with fibromyalgia will have really good days and my goodness, they want to get out there and they want to do all sorts of thing because they feel great.

>> The problem is with fibromyalgia more than the the person without fibromyalgia, a person with fibromyalgia will feel it more the next day and you can be profoundly tired in Arkansas if you go out and over do it so you want to exercise and get out and move around a little bit to the degree that you can tolerate but be careful about overdoing it itself.

And of course one of the best exercises four fibromyalgia will be do some aerobics swimming where you're getting in a warm water type of environment.

A hot tub is often very nice for a lot of people with fibromyalgia but you have to find out what really helps you because as we're getting into the winter months, people with fibromyalgia will typically have more aches and pains especially in winter months.

>> So in October , for instance, we often hear about a lot people coming out of the woodwork talking about more aches and pains and tiredness and fibromyalgia.

>> It's technically a rheumatology condition because the criteria for fibromyalgia was determined by the College of Rheumatology Clinicians but they will readily tell you that from their perspective it's more of a neurological condition because it's more of a condition that doesn't affect the joints and the cartilage as they originally thought.

It affects more of the nerve firing so if you really were to determine what fibromyalgia is as more of a neurological condition where your little nerves have an itchy trigger finger and that increases the pain impulses up the spinal cord now is there a directorially kinship with fibromyalgia and bipolar disorder?

No, I mean there's not a higher likelihood you're going to have bipolar disorder if you have fibromyalgia and not a higher likelihood you're going to have fibromyalgia if you have bipolar disorder they don't tend to correlate as medical conditions but they do as you identified tend to feed off of each other.

If you're having more trouble with fibromyalgia pain, it can disrupt your sleep.

It can affect your your mood in various ways and it will go back and forth.

>> So I'd suggest be that bring up these kind of conditions to your clinician and just try to have your clinician identify ways you can treat both conditions with as few medications as possible and very importantly treat be treated with medications that won't make one condition or another worse.

>> For instance, you don't want to give a medication as an answer depressant medication that also helps with fibromyalgia.

You might feel great from fibromyalgia standpoint but if it makes your mood swings worse and you have more highs and lows that could be problematic for a lot of people.

I've seen that happen with people who have taken for instance, develop Zavala's a very nice energizing activating medication that specifically does treat fibromyalgia and it's used for fibromyalgia.

But the issue is savola is that it sometimes will make the moodiness worse for some people if they have bipolar disorder the key with bipolar disorder in any case, whether it's bipolar one or two is you want to be on some kind of mood stabilizer and that mood stabilizer can be lithium, Depakote, lamotrigine and it can be a medication that also serves as a antipsychotic.

We don't like to use those terms anymore because these so-called antipsychotics are used for so many different things but some kind of medication to block dopamine.

So various medications out there will block dopamine.

They serve as antipsychotic medications and they serve as mood stabilizers Zyprexa, Allatoona, Abilify can apply to these are all medications that can help with mood stabilization but they would not typically make a condition like fibromyalgia or worse be.

>> Thank you for your call.

Let's go to our next e-mail.

Our next e-mail reads Dear Dr. Fauver, I have a relative who self medicate with alcohol when things aren't going well.

Can you give me some advice on how to encourage him when things aren't going so well?

I often worry about this person.

It's a relative who self medicating alcohol.

Well, I think you nailed it right there.

We don't want to really approach people who have trouble with alcohol as being morally flawed.

It's it's a condition where some people and not everybody when they start drinking alcohol they just take off with it and they start drinking more and more.

They have trouble with getting used to it and they don't stop at one or two drinks.

They continue to drink excessively.

It becomes a problem for them.

So as a as a friend as a relative yourself, you can identify that you're seeing they're having some problems and if they're self medicating as so many people do try to identify what they're trying to self medicate and encourage them to try to get some treatment for those underlying conditions.

I remember ten years ago I was making rounds on an inpatient hospital unit.

I saw this man who was knocking down a couple fifths of vodka a night and of course he was identified diagnosed as an alcoholic and he was an alcoholic classes.

But I talked to the fella and I realized he started drinking because he couldn't sleep OK, well so why couldn't you sleep well?

He was having these highs and lows just like be mentioned with bipolar disorder.

The highs and lows were indicative of bipolar disorder and he had never been treated for bipolar disorder.

>> So here's a guy who is being who is self medicating with alcohol and extremely high levels of alcohol as a means of trying to help him sleep.

But if you look at his underlying history, he would have highs where he couldn't sleep, he didn't need to sleep and he was off and running and he felt agitated and anxious during those high but then he crashed into lows.

So then he started using alcohol to try to treat the lows.

One thing led to another.

So at some point we have to really take a look at why people are drinking often ask people when you first had your first four first few drinks as an adolescent, how did how did how did it feel if somebody says when they drank as an adolescent and they felt great it was a wonderful euphoric, happy feeling those people are at highest risk for getting in trouble with alcohol later on so the people who really feel happy when they drink are the ones who later on can get in trouble with it.

>> Other people will say they get a little bit of a buzz.

They may feel a little bit tired.

They might not have as much problems with it but the people who give me the biggest warning signs are the young adults who are saying they they drink alcohol because it really makes them feel happy.

Those people probably have an underlying depression that need to be addressed.

So we want to identify what the underlying condition will be.

We want to address that condition.

Also keeping in mind for the craving for alcohol, there are so many different treatments out there nowadays to physiologically decrease the craving for alcohol.

They work at the level of the brain to decrease your desire for alcohol and of course there are some very, very good treatments from a psychotherapy standpoint for alcohol to try to remind people that it's something that it can be problematic for them alcoholics Anonymous has been around for eight decades now seven decades, been around for a long time.

Alcoholics Anonymous is a remarkable means of support supporting other people who also have similar problems with alcohol.

>> Thank you for your question.

Let's go to next caller.

Hello Deb.

Welcome to Mastermind.

Debbie had mentioned that or you had wondered has the you had said you have brain damage and you find it difficult that you can't walk properly when you're under stress?

>> Could there be a correlation with walking properly and being under stress?

Yeah, the brain does not only modulate stress but it also affects your ability to walk, the ability to walk and your difficulty with the brain damage or the stroke or the head injury, whatever you might experience probably affects a side part of the brain over here and the ability to put up with stress is down here in the amygdala which I mentioned earlier.

>> The amygdala is the volume control for anxiety, anger, rage.

It tends to calm down the anxiety for people but the front part of the brain is the part of the brain that you use to try to think through your life's difficulties.

So how do you think through your life difficulties?

Well, many times it comes back to your past experiences and how you've dealt with past experiences.

Secondly, it comes down to coping strategies and coping mechanism that you've developed and created over the years in your dealing with life circumstances.

And finally there's some genetic aspects of dealing with stress, putting up with things, having resilience with stress.

That's something that can have to some degree a genetic component.

So we look at all those different factors and what we're trying do in psychiatry when we're trying to help somebody deal with stress a bit better will be to fire up the front part of the brain now sometimes the front part of the brain it just is not working so well.

So you have difficulty putting up with even little things.

So in those cases yeah.

Medications of various types based on the condition at hand can help people put up with stress better.

>> Now if you've had a head injury and you had difficulty walking due to the head injury and you had a frontal head injury that might have given you difficulty putting up with stress, we might use antiepileptic medications for those people because difficulty with stress and dealing with that to resilience related to the stress can affect to walk which like I said is affected in this part of the brain.

So we often want to look at it too.

But I'd want to know what kind of head injury you experienced and was there a correlation between the difficulty with walking and putting up with stress because so many people with a head injury will have this excessive outflow of a chemical called glutamate glutamates and excitatory chemical in the brain and it's you got to have just enough of it.

>> You don't want to have too little but not too much.

If you have too little glutamate it can affect your mood.

It can affect your concentration too little glutamate can give you difficulty with processing information but excessive glutamate which is often released at higher than average ,a higher than usual amounts excessive glutamate can give you seizures.

You can give you difficulty.

The irritability can give you trouble.

>> Moodiness and excessive glutamate inadvertently could cause you to have difficulty with personality disturbances that could thereby affect this area of the brain affecting the walking.

So yeah, there could be a connection between the difficulty walking and putting up with stress and we just have to look at the cause and effect of those type of things and determine the best way to be treated.

But you want to stick with physical therapy because physical therapy is the best way to try to recover from any hint of head injury that's causing you some difficulty with walking.

>> Thanks your call.

Let's go to our next email.

Our next email reads Dear to the father.

I have a I've had a few major disappointments as of late regarding my job and family.

How long should it take for me to move on?

At what point should I seek professional therapy?

>> Generally it's a variable amount for moving on with stresses in life circumstances.

But number one, you have to really determine what you can do about your situation and what you can't.

So you've got job family difficulties and disappointments sought out what you can control and what you can't and then the things you can control try to do something about them and create a checklist concerning the different things you're going to do about the life disappointments and the opportunities that might be available and see if you can address those for various people depends on how those situations come out.

Variable amounts of time can evolve concerning how long you get over different things but you seek professional help when you are specifically having trouble with getting things done day by day by day socially going to work, being around people.

Other people say that you're less sociable if you're having trouble with eating, if you're having trouble with sleeping that's where you seek professional help.

>> We call it functional impairment and that's what crosses the line and becoming a and becomes a psychiatric condition that you want to have treated.

>> Thanks your email.

Unfortunately I'm out of time for 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 at WSW again I'm psychiatrist Jeff Over and you've been watching matters of the mind God willing and PBS willing.

I'll be back again next week.

Thanks for watching tonight