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Good evening.

I'm a psychiatrist, a father live from Fort Wayne , Indiana.

Welcome to Matters of the Mind now in its 25th 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.

PBS Fort Wayne by dialing in the Fort Wayne area (969) 27 zero or if you're calling any place else 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 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 óg that's matters of the mind at WFYI org or start tonight's program with a question I recently received.

>> It reads Dear Dr. Fauver how do I know if it's time for me to try a different medication?

I've been using bupropion for several years now to treat moderate depression and most of the time it seems to be effective.

>> Lately it's been less so I'm worried about dependencies so I want to be careful about new medications.

>> Understandably you'd be concerned about getting hooked on a medication or getting dependent on a medication.

>> But if you're taking a medication like bupropion which is primarily increasing dopamine and norepinephrine in a non addicting manner typically and it's not working so well for you anymore, I want to try to explore other possibilities on why you're not feeling well.

>> For instance, sometimes a medication like bupropion will seem like it's not working when you have other medical conditions emerge such as sleep apnea, very common condition where people will snore at night, they might pause in their breathing and they don't get enough air flow to the lungs with less air flow to the lungs.

>> They get less oxygen to the brain, makes them tired, makes them depressed.

They can't think the next day.

>> So sleep apnea is a possibility that might be emerging as the years have gone on.

A second possibility could be low thyroid hypothyroidism is is a very common phenomenon that occurs especially with women but it does occur with men and it is genetic to some degree but it can cause you to feel fatigued and tired and many people will perceive it to be related to depression.

Loth and it can be a possibility especially for heavily menstruating women, especially if they're vegetarians and diabetes.

We have Type two diabetes that's emerging in our society over the past 50 60 years and with type two diabetes your blood sugars will go high and sometimes too low and with Type two diabetes that can cause you to feel fatigued and have poor concentration lack of get up and go and you just don't feel right.

So I want to make sure you didn't have those medical conditions first.

Secondly, if an antidepressant is no longer working out also wonder about any psychiatric conditions I might be going on.

Did something happen in your life more recently it might have triggered more depression is not being effectively treated with the Wellbutrin or do you have a condition like bipolar disorder with bipolar disorder you can have manic highs lasting for anywhere between one to seven or eight days and then you have these depressive lows and people will often perceive that an antidepressant medication like bupropion can work just fine with the depressive lows.

But if you have the highs it's more likely you're going to have the lows and then you cycle back and forth, back and forth.

>> Most people notice the highs and lows in their 20s or so and as the years go on the lows will get more prominent but the highs will sometimes still be there in the background and if you still experience the highs that can actually be a predictor for you having lows.

>> I'd want to know what kind of medication, if any your family members might have taken and had they had similar experiences with a medication like bupropion didn't work for them anymore.

>> Now bupropion as I mentioned does increase norepinephrine and dopamine and unlike medications that increase serotonin, it doesn't tend to have this effect where I just no longer works as time goes on now the medications that increase serotonin are more prominent to cause that the technical term is out and that's a term that's been given to these medications when they just seem to no longer work and we've seen it with Prozac, Zoloft, Paxil, Celexa, Lexapro.

>> These are medications that predominantly men almost exclusively will increase serotonin transmission and if you just increase serotonin transmission you can indirect decrease dopamine transmission when that happens, decreasing dopamine transmission in the brain you can feel like you're less motivated.

>> You don't have much energy, you can't think very clearly and you feel blah.

And some people will describe the feeling of being on the serotonin, the medications as not feeling happy, not feeling sad.

They just kind of feel emotionally flatlined.

So they just have limited emotions overall and they have this emotional dulling effect and they don't like they don't like how they feel.

They don't cry as much anymore obviously but they just don't like having this emotionally dull perception that's more prominent with the serotonin medications less likely with something like bupropion which is primarily increasing dopamine and norepinephrine.

>> So talk to your clinician about various possibilities on why the bupropion might not be working so well anymore.

Perhaps you're on too low of a dosage.

>> About one out of four people will do really well with a dosage as low as one hundred and fifty milligrams a day and maybe you're on that low dosage for a long time and it was never increased and now you're at a point in your life where you need the higher dosage.

>> A typical dosage for bupropion will be three hundred milligrams once in a while we go higher than that but 300 milligrams is the most common dosage we do genetic testing and genetic testing will sometimes give us some clues on how high we should go in the bupropion dosage there's a gene called C OMT Kartika or methyl transfer assumed has a genetic makeup that can sometimes tell us if somebody needs a higher dosage or a lower dosage and bupropion goes through this little enzyme in the liver called Cytochrome P 452 B six and if you're a fast B to be six metabolism you're going to need more bupropion or Wellbutrin if you're a slow to be six metabolize or you need the lower doses.

>> So sometimes it'll be a bit of a tip off on what the dosage should be.

So there's a lot of things there to discuss with a clinician but bottom line is go talk to your clinician and say this isn't working as well for me as it did before.

>> It might have nothing to do with the bupropion.

I might have more something more with something to do with another medical condition like sleep apnea, diabetes, low iron or low thyroid.

>> Thanks for your email.

Let's go to our first caller and our first caller is Jay .

>> You have a question go ahead .

>> Do you have a question?

You have a question about brain fog and you want to know what does brain fog entail and why might it occur while Jay brain fog is a condition where you have a slower speed of processing and with a slower speed of processing, you'll notice that your brain just doesn't think as clearly as it did before and you'll notice that you don't go from one topic to another quite as quickly.

>> It's like having a slow computer speed way back in the old days we had the old connections on the on the computer where you had this slow dial up connection and it would go very slowly from one speed to another.

We call that microprocessor speed in the with computers.

Well, it's kind of the same thing with a central processing unit or a CPU that's slow in the computer.

>> Well, if when you get depressed you can have brain fog and you can have slow processing speed in the brain and is primarily due to this front part of the brain which is in the left frontal part of the brain is called a dorsolateral prefrontal cortex.

The front part of the brain is a is important for attention span focus and it's thought that when people have difficulty with slow processing speed that is a factor in itself.

>> Now there's a part of the brain that's involved in the overall networking in the middle part of the brain and sometimes it'll get stuck in this background let's call it a default sleep mode where you're not asleep but your brain just doesn't really turn on and get thinking and when it's when it's in that background sleep mode you just can't start thinking very clearly about new information and you just can't turn it on so much.

This is a condition is prominent with people with depression.

So when you have depression you'll have a hard time turning on the brain to really start thinking and concentrating on tasks at hand and you'll have trouble with what many people call brain fog.

So when I hear about brain fog number one I am thinking about the possibility of an underlying clinical depression which is often accompanied by lack of enjoyment of things low motivation, low energy sleep disturbances and appetite disturbances not uncommonly so that's one reason for brain fog, another reason for brain fog can be if you've had the after effect of what's called the long Horler syndrome of covid I've seen this in many cases with people who have endured covid over the past several months.

They still have difficulty with brain processing speed and they have difficulty with brain fog from the after effect of covid.

>> So I'm often asking about that if somebody is experiencing the after effect of covid especially if they have difficulty with irritability, moodiness, racing thoughts we might consider a medication like lithium lithium as a salt that has antiinflammatory effects and it seems to be particularly helpful for people who have endured covid and the after effect of that with with the racing thoughts and difficulty with concentration.

If you have trouble with covid related brain fog like you'd mentioned with the brain fog we might consider Wellbutrin or bupropion which I talked about previously or perhaps Trantor or Vaud Occitan which is also very good for the speed of processing as well.

Brain fog can also be related to medical conditions.

>> I mentioned those before sleep apnea low thyroid will often hear about brain fog with diabetes when somebody has high blood sugars or low blood sugars and sometimes low iron will give people brain fog.

So we want to make sure those medical conditions are assessed and treated accordingly if need be.

>> And if you've had some kind of medication recently that might have contributed to brain fog, that can be a factor too.

Will sometimes hear about brain fog when people have had chemotherapy for cancer and that's basically where the chemotherapy itself can give you difficulty with processing speed.

And we'll occasionally hear about brain fog when people are taken antidepressants.

It sounds odd that some antidepressants would give you brain fog but again the serotonin medications by increasing serotonin can indirectly and secondarily decrease dopamine and when you decrease dopamine you can have difficulty with concentration of thinking.

>> So that can be a factor as well.

Brain fog can also be related to not getting enough sleep so if you are only getting three and four hours of sleep every night and you get by most commonly a seven or eight hours and that's the most effective amount of time of sleep that you need.

Yeah, lack of sleep can give more difficulty with speed of processing the next day because sleep is needed to recharge the brain and it's kind of like getting your battery not adequately recharged when you're not getting enough sleep.

So lack of sleep can give you difficulty with brain fog the next day not uncommonly when people have brain fog they often will have difficulty getting through the day and concentrating and trying to do one thing after another and changing from one task to another.

So we try to address that the best we can.

There might be inflammatory components to a medical component to it and medicine components to it but we want to try to sort all those out to figure out the best way to help your brain start to work.

>> A lot of people in their forties and fifties will perceive that they're having symptoms of early dementia when these type of phenomena are occurring and has nothing to do with dementia, they're just having trouble concentrating and thinking due to those other types of factors they can relate to brain fog.

So we try to address the underlying problem and then go from there.

Gee, thanks for your call.

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

>> Our next e-mail question reads Dear Dr. Farber, I've been treated for minor anxiety and depression successfully.

The medications and therapy have all worked pretty well.

The one thing that is still an issue is my sleep.

I'm still having trouble getting enough.

What's my first step?

>> Well, you take a look at your treatment for depression anxiety.

We want to know what kind of medications you're taking.

>> The first thing we want want to consider is will will any of the medications you're taking possibly be a factor in keeping you awake?

So as a side effect, some medications can keep you awake and interfere with your sleep if that's not the factor, OK, then we move on about three fourths of psychiatric conditions have an underlying sleep disturbance associated with it and if we can get somebody sleeping it makes a world of difference for a lot of people.

So for many, many cases we like to get people sleeping.

You might have heard of the older medications like Ambien, Lunesta, Procyon these are medications have been been around for a long time and they will knock you out Senada Restoril just to use some trade names here these medications will knock you out and you'll be sleepy.

>> But unfortunately they can interrupt the sleep architecture or where you might not get a good quality of sleep and feel very refreshed the next day but they'll knock you out at least you'll feel like you get a good night's sleep.

>> We don't like to use those knockout medications for more than a couple of weeks if at all possible and ideally not use them at all.

So what do you do to get a better night's sleep?

Well, to get a better night's sleep you have to look here over overall sleep hygiene.

Are you trying to get to bed when you're sleepy?

We all have a circadian rhythm and this homeostatic rhythm where we we tend to get sleepy about the same time every night that's just now naturally it works.

>> However you can work you can work past that sleep urge and fight through it by doing something that's interesting and exciting and you can watch a football or a basketball game, you can watch an interesting movie and you can stay awake past that urge to go to sleep.

So let's say your urge to go to sleep is at ten thirty at night.

If you're watching an interesting game or watching an interesting movie you can stay awake past that ten thirty urge.

>> Well the next thing you know you're not going to be sleepy again till midnight and then another hour and a half goes by.

It's like catching a bus every hour and a half.

If you miss that bus now you'll be awake longer and longer and if you awaken in the middle of the night and it's about one thirty or so and you're wide awake, there's a pretty good chance you're not going to go back to sleep until two thirty or three.

So the best thing to do in those kind of situations is to get up and just read something that's not very stimulating.

>> Don't get on your don't get on your smartphone or don't watch television because the brightness of the light can actually keep you awake and stimulate your wakefulness by doing that.

>> So read something in relatively dim light just to allow you to get sleepy again.

But if you're wide awake at one thirty or so in the morning chances are you're going to stay up for another hour, hour and a half before you get sleepy again and tossing and turning often doesn't really help so much so the first thing we always consider a sleep hygiene trying to get the bed the same time every night try to get up the next morning the same time of the day the best you can even if you're sleepy try to get up at a certain time every day on the same time every day.

>> That's the ideal thing to do for sleep hygiene.

Secondly, be careful about why you eat late at night if you eat a big meal, spicy foods especially late at night that can be a factor in keeping you awake if you exercise which would be fantastic for sleep.

Exercising in the morning is ideal.

Exercising later at night can be a factor in keeping you awake.

I'm a big advocate of exercising any time during the day but some people when they sleep, when they are asleep at night, if they've had some exercise since 7:00 p.m. especially as we get older it sometimes will keep your weight can be a factor when you go to bed, get the TV off, try not to watch television within 30 minutes of going to bed because again the bright light of the television keep keep you up if you need a medication on top of what you're already taking.

>> Well there are medications that are safe and not addicting and they're commonly used for sleep melatonin is fine.

>> Up to five milligrams at bedtime typically will help you get to sleep but it won't necessarily keep your sleep.

>> Melatonin basically is a natural hormone that comes from the pineal body which is right smack in the middle of the brain right there.

>> It's about the size of a pea and melatonin tends to rise when it gets dark and that's why it's called the vampire hormone as it gets dark outside melatonin rises and five milligrams of melatonin or less can be effective in giving your brain the chemical signal to go to sleep and melatonin is like a puff of smoke.

>> It lasts for about 30 minutes or so and then it's gone so it's not going to keep you asleep but it can give your brain the chemical signal to go to sleep.

I would not recommend antihistamines to go to sleep such as Benadryl or diphenhydramine because it can affect the concentration, memory and focus for the even the next day.

>> However, prescription medication could take for sleep would be something as simple as gabapentin also used for seizures and for fibromyalgia and for neuropathic pain.

>> Gabapentin has been effectively used for sleep.

>> Trazodone has been around since nineteen eighty one is an antidepressant and it will help people get to sleep and stay asleep.

It's mainly affecting serotonin receptors so it's very good for giving people a good depth and quality of sleep and it could be used for years.

It's something that lasts for about eight hours and it's gone and a medication called Doxa Penn at very low dose is three to six milligrams at bedtime has been available in the parade trade name called Silencer.

But Doc Spin comes in a liquid formulation.

That's what we often use the document solution three to six milligrams at bedtime can help a person get to sleep and stay asleep while not causing all the side effects that the antidepressant doses of aspirin can cause when Tuxpan is used as an antidepressant it's dose between 50 and 150 milligrams at bedtime for sleep all you need is three to six milligrams at bedtime and the most inexpensive way to use that is in a solution form and we all we will often prescribe that.

>> Thanks for your call.

Let's go to our next caller.

Hello Rick.

Welcome to Matters of Mind.

Rick had mentioned they've gone through a lot of traumatic experiences and you've seen a mental health decline and you want to know what I'd recommend to help you cope ?

>> I want to know first and foremost, Rick, with those traumatic experiences that you've endured, what specific symptoms are you noticing with traumatic experiences if they are overwhelming and you lack the ability to cope with what you've gone through and it's starting to affect your sleep as I mentioned a couple of times already, tonight's lack of sleep will affect you in so many different ways.

>> It will affect your ability to put up with stuff.

It'll affect your resilience.

That's a fancy term for stress tolerant so it'll affect your judgment and your ability to think through your problems.

So you're off the bat, Rick, if you're having difficulty sleep I want to address that.

>> If you could do a traumatic experience, I'd want to know on one hand is it get you down and depressed to the point where you're withdrawing from other people you're not having fun anymore is that traumatic experience is causing you to give up on life and even thinking about death or suicide?

My goodness.

People would give up when they endure a lot of trauma.

Is it affecting your appetite?

Is it affecting your energy level?

We look at all these different symptoms associated with depression and address those accordingly and another issue explore would be post-traumatic stress.

It's a real phenomenon but people who have endured traumatic experiences will sometimes experience post-traumatic stress symptoms such as avoidance of situations that remind them of the past trauma.

They will be very jumpy.

We call it hyper vigilant where they are very on edge and they're always expecting something bad to happen.

>> Many people when they've endured traumatic experiences will actually have flashbacks and they'll see an reexperience and relive the past trauma itself.

We see this not uncommonly with people who have been assaulted or they've been in combat or they've been in motor vehicle accidents.

>> So that could be very troubling for people.

So if you have post-traumatic stress we would treat that in a different way with post-traumatic stress.

>> If it's a recent post-traumatic stress event especially we might consider eye movement desensitization reprocessing MDR is a means by which the frontal lobe kind of gets re networked based on watching the finger of the therapist and like the name implies I I eye movement and desensitization and reprocessing MDR.

>> It all has to do with eye movements and how it can change the frontal lobe and the reason I want to do that to change the frontal lobe networking is because the frontal lobe is the reasoning part of the brain and the whole idea behind MDR is to help the frontal lobe be able to work more effectively.

So that could be something and specifically effective for especially recent traumatic experiences.

Sometimes dialectic behavioral therapy can be helpful for people who have had long term traumatic experiences and obviously cognitive behavioral therapy, interpersonal therapy if it's having if it's causing you difficulty with getting along with people, they can be helpful especially for people who have had depressive symptoms.

So basically, Rick, you would review all these different symptoms and how the past trauma traumas have affected you with a mental health clinician and then from there you determine what direction to go from there.

>> Rick, thanks for your call.

Let's go to next.

Hello Karl from Huntington.

Welcome to Matters of Mind Karl.

>> You're looking for attention deficit hyperactivity disorder or add medications for adults versus children?

Well, for adults and children we have medications that are used for attention deficit disorder.

ADHD is the type of attention deficit disorder where you also have hyperactivity such as fidgeting difficulty with sitting still impulsivity, doing things and saying things you ordinarily shouldn't do.

>> ADHD or add is a phenomenon where you have trouble attention span, distractibility focus on a day to day basis and it goes back to childhood so it starts in childhood and about 60 percent of people grow out of it significantly by the time their front part of the brain fully develops the age of twenty four years old.

>> But the problem is when you have attention deficit disorder or add or ADHD you can have these other kind of symptoms that go along with it such as anxiety, depression.

>> You can have trouble getting using substances of abuse.

Many people with ADHD will have the tendency toward to want to use nicotine as a means of self medicating and then for anxiety people will use marijuana, alcohol and they have all these other problems that go along with it.

>> So we want to try to treat the underlying core symptoms of ADD and in doing so we can often help with the anxiety and depression that go along with a stimulus work very, very well for a lot of people about 90 percent of people have a very nice effect on an amphetamine agent or a methylphenidate agent.

The amphetamine agents predominantly are Vyvanse.

The medications like dextroamphetamin these are amphetamines and you have the methylphenidate agents which are the Ritalin products that you might have heard about over the years.

>> The bad rap on the especially the Ritalin products is clinicians historically have dose them way too high and when you dose them too high you kind of get this robotic effect where you lose your personality when you're taking medication.

>> So when we use stimulants we want to use the stimulus not unlike how we would adjust eyeglasses strength for somebody with poor vision with with poor vision.

>> Yeah, you could get through life with poor vision.

You could survive with poor vision but it's a difficult time with your quality of life and when you get eyeglasses and corrective lenses it can make a dramatic difference on your ability to get through life and your efficiency and getting things done.

>> The same is true for ADHD or ADHD is a phenomenon where the front part of the brain is a bit underactive your distractible you don't have the attention span you should have and you have a hard time reading not uncommonly following conversations.

You'll be very anxious in social settings not uncommonly because you're hearing all the conversations at one time and people with ADHD tend to have high cues that are higher than people without ADHD that they just can't get things done and they're not efficient in getting things done.

So stimulus work very well.

Other medications that can work well will be medication like Strattera Atama Occitan which is a non stimulant works in about 20 percent of people really well these are the twenty percent of the people who just don't do well with a stimulant.

So Adam Occitan or Strattera can work quite nicely especially if somebody has a little bit of depression.

>> But sometimes even if they don't a medication bupropion or Wellbutrin which I mentioned at the start of the program, bupropion or Wellbutrin has about half of a stimulant effect of a true stimulant.

So it does increase norepinephrine and dopamine but not as strongly as a stimulant will but it can give you 24/7 help with the symptoms.

So there's a lot of different treatments out there to enhance dopamine or norepinephrine and then we might consider medications like want forseen Clonidine is another medication.

>> These are so-called Alpha two agonists and these are medications that used to be used for blood pressure but they worked nicely with the medications such stimulants because the medications such as stimulants will tend to increase the blood pressure fussin and clonidine will decrease the blood pressure.

But the Gwynfor seen in quantity will specifically help with impulsivity, irritability, anxiety and sleep disturbances that are frequently seen with ADD or ADHD.

>> Carl, thanks for your call.

Unfortunately I'm out of time for this evening if you have any questions that I can answer on the air concerning mental issues, drop me an email at Matters of the Mind all one word at WFA dot org.

>> I'm psychiatrist Jeff Offer 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