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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 of Matters of the Mind is a live call in program where you have a chance to choose the topic for discussion.

So if you have any questions concerning mental health issues, give me a call here in the Fort Wayne area by dialing (969) 27 two zero or if you're calling coast to coast you dial toll free at 866- (969) six nine two seven two zero now on a fairly regular basis we are broadcasting every Monday night from our spectacular PBS Fort Wayne studios which lie in the shadows of the Pardoo Fort Wayne Campus.

And if you'd like to contact me with an email question that I can answer on the air via during the live show you may write me via the Internet at matters of the mind all one word at WFB org that's matters of the mind at WSW, ECG and I have several emails that have come in over the past week.

>> The first one reads Dear Dear Father a friend of mine is on 20 milligrams of Lorestan.

It's also known as Latouche to daily and experiencing headaches and agitation and with increasing it to 40 milligrams help with these side effects of 20 milligrams of latitude is a very low dosage and typically altitude at low dosages can cause some adjustment difficulties.

But on the other hand if you increase the dosage the side effects might worsen.

Now if you had headaches and agitation before you took Tuta and they didn't get any better, yeah, you might want to increase the dosage up to 40 milligrams.

>> But if you notice that you are experiencing headaches and restlessness at low doses, it's not highly likely it's going to improve going to a higher dose.

As a matter of fact, the headaches and the restlessness might worsen.

There's a phenomenon called akathisia and akathisia can be a side effect to Allatoona and medications in that class and basically a catheter is where you have a hard time sitting still.

It's not just shakiness, it's not a tremulousness.

It's where you have a hard time sitting still and we often see people with Athelia in our office where they just can't sit in their chair and they'll walk around and have difficulty sitting still.

We'll actually see this on video visits as well where people will need to walk as they're talking to us and it leads to a great deal of discomfort for a lot of people.

>> So with little to twenty milligrams every day you can see these kind of side effects increasing the dosage might make it worse.

But like I said, if you're mildly if you're mainly having difficulty with headaches and difficulty the agitation and those are the reasons for which Allatoona is being used.

Sure.

Increase the dosage could be helpful for that if that was the main main target cluster of symptoms that were there before you started taking the latter to.

So 20 milligrams is a very low dosage for some people once in a while it will go away the longer you wait but I wouldn't increase the dosage if it is thought to be contributing to side effects because side effects typically are dose related often tell people that we often will use two or three different medications that have entirely different mechanisms of action for the purpose of minimizing side effects because side effects typically get worse as you go higher on the dosage.

Now if you can hang in there for a long period of time sometimes they do go away but side effects typically are related to the dosage of the medication and occasionally I'll hear somebody say they had a lot of side effects from from a medication.

We find out that they were taking a fairly high dosage of it.

We can reintroduce that medication at a lower dosage and the intention will be that it will be more tolerable and they'll have still the benefits for the medication because going higher on medication will not necessarily be beneficial for everybody.

La Tuta is a medication that goes to a particular metabolic pathway.

Some people are slow metabolism and very small amounts will be all they need.

Such at twenty milligrams for a lot of people is a low dosage.

Well if you're tend to be a slow metabolism you can maybe get by on half of that dosage and a lot of cases.

So it's medication.

It typically is fairly well tolerated but if you're noticing side effects early on at a low dosage either stay at that dosage or cut it down under your clinician's supervision.

But I certainly wouldn't recommend increasing the dosage if you're already having side effects to it.

>> Thanks for your email.

Let's go to our next email.

Our next e-mail question reads Dear Dr. Fovea stopped by so I thought I saw it there.

Nope, I guess I haven't seen it yet.

>> I remember an email question that I had that pertained to a person taking there it is there twenty five for twenty five years they've been using talk therapy or counseling and they've taking fluoxetine eighty milligrams a day for depression.

Eighty milligrams a day for depression is a fairly high dosage when fluoxetine is introduced back in nineteen eighty seven it was thought that most people could get by on twenty milligrams a day and over the course of time there were a couple conditions where people were thought to be able to tolerate a higher dosage of fluoxetine going to sixty or eighty milligrams a day and those conditions were obsessive compulsive disorder and binge eating disorder and for those reasons those doses will often be increased.

>> Let's go back to the email there.

Eighty milligrams is a fairly high dosage for depression and you'd mentioned that recently I've felt more empty and hopeless so I'm heading toward a major depressive relapse.

Could it become as severe as it was when I when I was first diagnosed?

>> Should I expect other major relapses?

You can have a relapse from depression.

The more times you've had depression, the more likely you're going to have other depressive episodes.

>> You're also more likely to have depression if you are incompletely remitted from depression.

In other words, it's not unlike cancer treatment if you have a cancer and the cancer hasn't entirely remitted in other words the cancer is not entirely gone away it's more likely that cancer will creep up.

Depression is similar if you've had a depressive episode and you're not feeling well not happy all the time none of us should be happy all the time.

>> But if you're not feeling well to the point where you have normal ranges of mood with happiness, anxiety, depression, apathy, irritability these are normal ranges of of of mood that should occur based on your life circumstances.

Those are OK.

But if you have an unnatural depression more days and not accompanied by disturbances with sleep energy appetite and so forth that could mean the depression has not remitted and if that occurs you're more likely to have relapses with depression not unlike the people with relapses with cancer if they've not remitted.

So what will often consider you've been on Prozac or Fluoxetine twenty or eighty milligrams a day?

The first question would be was that too much for you because sometimes people experience depression at twenty milligrams a day of Flock's team and they'll go higher typically to forty milligrams than sixty and then eighty milligrams a day.

>> So the first question I'd have for you would be did going to eighty milligrams a day give you significant relief compared to sixty milligrams or forty milligrams a day because we're always trying to find that sweet spot.

What was the dosage that really helped you the most in terms of helping you with depression ?

Did you get any further benefit going from 20 to 40 to 60 to 80?

If not, let's go back down to twenty milligrams if you had at least a 50 percent or more improvement at twenty milligrams.

Now keep in mind since Flock's team became available back in nineteen eighty seven, we've had about sixteen different oral antidepressants become available.

So we've had a lot of other antidepressants become available.

There's a new one that's coming becoming available this month called Ability and it will be a medication it's an oral medication to be taken twice a day that works entirely unlike anything that we've had previously.

>> So if Fluoxetine eighty milligrams a day is leaving you'd feeling empty and apathetic and kind of feeling dull and have this emotional void.

It might mean that you've taken too much of it and also might mean that you're getting a little bit too high of a dosage on it.

>> So we might consider going to a different type of medication that has a different mechanism of action.

Flock's team primarily will increase serotonin transmission and for about one out of three people that's fine and that works out for them.

>> But for two out of three people increasing serotonin by itself might not do the trick for them because if you increase serotonin long term sometimes that can indirectly decrease dopamine.

>> If you decrease dopamine you can feel blah and emotionally dull and kind of empty.

So we'll often have people go to a medication.

It doesn't just increase serotonin but it might increase serotonin and norepinephrine medications like fith Zema Cymbalta Presti Effexor do that we might have you change over to a medication that primarily increases dopamine and norepinephrine that could be Wellbutrin and we might have you consider a medication that has various effects on norepinephrine serotonin, dopamine, glutamate for that matter maybe like train Telek.

So there's a lot of other medications out there available for you that you can consider.

But the ultimate goal in treating depression is not just to get you feeling better, it's actually to get you feeling well and having that empty emotional void feeling and sensation that you're experiencing that's not normal and that should be something that should be addressed for you.

So talk to your clinician about what other options might be available for you but also look back and try to consider how you felt as you increase the dosage on Fluoxetine.

Did you feel any better with each increasing of the dosage because you might have gotten to a point where you actually felt worse on the higher dosage.

>> So with team like many medications and going higher and higher is not necessarily better for everybody.

I often compare it to eyeglasses getting thicker and thicker eyeglasses.

Is it going to work for everybody?

If you need the thicker lenses fine but not everybody does well those thicker lenses in the same way not everybody does well with higher doses of medication.

>> Thanks for email.

Let's go to our first caller.

>> Hello Deb.

Welcome to Matters of Mind.

Well Deb, you had mentioned that you had once heard me say that people over the age of sixty five years of age shouldn't take allergy medications and you'd like me to explain what I meant by that allergy medications of a specific type.

Deb, there's one particular allergy medication that concerns me for those of us over 65 years of age is called diphenhydramine diphenhydramine also known as Benadryl.

So Benadryl is a medication has been around for a long time.

A lot of us have heard of Benadryl.

Many people have taken it for allergies.

Many people take it for sleep.

But as we get older over that magical age of 65 years old, what we should do is try to avoid medications that have a so-called anti cholinergic effect and anticholinergic effect is where a medication blocks this chemical called acetylcholine.

Acetylcholine is very important for memory and concentration and people with dementia for instance Alzheimer's dementia often have decreases of transmission of acetylcholine and that's thought to be one of the reasons why you have dementia memory problems.

>> Diphenhydramine is a powerful anticholinergic medication.

It helps block histamine and that's fine but it's strongly will block the acetylcholine transmission causing people to have memory disturbances.

>> They actually did studies on people who took diphenhydramine or Benadryl at bedtime as a sleep aid which many people do and they did driving test the next morning up until noon and they found that they had significant driving disturbances even though they kind of felt awake the next morning.

So I often recommend other types of medication for sleep rather than diphenhydramine or Benadryl not for younger people that can be fine as long as it doesn't cause them to have a paradoxical agitation which it can do with younger people but with Benadryl or diphenhydramine, it's something that I don't recommend for anybody over sixty five years of age because we have so many other options you can take various antihistamines that don't get to the brain so much and don't have anticholinergic effects medications like Claritin, Alegra very good medications that are over-the-counter.

They're inexpensive and they don't get to the brain.

If you need something for sleep we often recommend other medications such as Trazodone, maybe low dose gabapentin perhaps docs happen at three to six milligrams at bedtime.

Those medications do not have these so-called anticholinergic effects and they would not be prone to causing trouble with memory.

>> Deb, thanks for your call.

Let's go to our next caller.

>> Hello Karen.

Welcome to Matters of Mind.

Hi.

Hi, Karen.

Okay, I have an iPhone be a fairly serious I phobia that I've had since I was a child and yes, my mom did things that made me be that way.

But in college I took or went to a counselor and tried to do relaxation therapy and it just he was not good and it made it worse.

So now I'm 68 and I've gone OK, you know I'll never have contacts.

I'll never watch people put in context.

I can't watch people rub their eyes, you know, all these fun things.

But now I'm 68 and I have cataracts and my vision is going and they're saying yes, you should have surgery.

Well, like yeah that's going to happen not in my present state of mind is there anything anything I can do about medication I can take I do take Prozac already for depression but is there anything that I can do that I mean it's it I can't drive at night now and it's it's getting harder to read stuff and but yeah like what are my options anything or just say oh my goodness Karen you're talking about a phobia where you're having difficulty with anybody messing with your eyes or having rubbing your eyes or just having difficulty with any sensation of something in your eyes.

>> Well mostly like yeah I'm at the eye doctor, you know I jump a mile for the air puff I got you Arkoma Chest and he tried do something I don't know what opened up my eye to see something in like I just it was it was not pretty and I don't I can't watch people put in their contacts.

I you know there was some show this week that some guy got a stick in his eye or something that I didn't see it coming until I did and I you know, went well you're wondering about the cataracts and I try to be careful about conveying my personal experiences with people because I don't know what you're going through and I'm not in your shoes but I did have cataract surgery and lens implants.

>> I completed what was it seventeen years ago was a while back.

>> So if you have the cataract surgery and you get Lintz implants as you would, you'll notice it can be a life changing experience.

You'll be able to see things more clearly.

It'll give you a better quality of life.

You're sixty eight years young so that means that you can have a lot of years ahead of you and if you don't have the surgery, if you don't have the cataracts removed which is a clouding of the lenses, you can unfortunately not only have a poor quality of life where you can't read, you can't drive at night, you can stumble and you can fall and then you've got a broken hip and then your life goes downhill from there.

The nice thing about the cataract surgery, Kiran, is they gave you some really nice tranquilizing medications where you just won't care so you will not experience the sensation of somebody working in your eye.

You'll notice it but you won't care.

>> So they give you medications that are very safe and effective on a short term basis during the surgery itself they give you a medication prior to the surgery to calm you down.

>> It's a short acting medication that gives you a nice relaxing effect and then during the surgery itself they give you more medication as a means of allowing you to be very calm.

So it's rare that people will say they feel a lot of anxiety during or even after the surgery because you're so chilled out it won't matter.

So I would say go ahead and pursue getting it completed.

It's not like you're going to have to force your eye open during the surgery itself because they'll take care of that for you because you'll be so relaxed and so calm that you should be able to endure quite nicely.

And the wonderful thing about having the cataract surgery and the lens implants will be that you get those lenses in there.

You can see sharper than you have in a long time and it comes down to a quality of life and a safety issue for for you, Karen, among other things.

But I would say go ahead and pursue it and just be reassured they can give you very, very relaxing medication as part of that surgery and help you get through it.

As I said, it's a it's a surgery I've had myself and have I had both lenses implanted and replaced and it can be life changing.

You don't have to wear contacts.

Yeah.

You might need glasses every now and then when you read fine print but for the most part you can see things at a distance very, very nicely.

>> Karen, thanks for your call.

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

Our next e-mail question reads Dear Dr. Farber, is there a connection between anxiety and heartburn?

My doctor says my upper or gastrointestinal X-rays show nothing significant and has me on point to five milligrams of alprazolam also known as Xanax one to two times a day.

How could breathing exercises help with anxiety and heartburn and what else could help breathing exercises can help with anxiety and heartburn on one hand because when you're breathing out you will have a nice relaxing effect and a lot of cases so many people have the breathing exercises where they breathe and they breathe out when they're breathing out they will have a slowing of the heartbeat and it gives them a nice calming relaxing effect so breathing exercises can help with anxiety.

Exercise is always remarkable for anxiety.

You want to be careful with resistance or weight training if you have any heartburn because sometimes by contracting the abdominal muscles you're flexing your core that can sometimes flare up the heartburn itself.

You've dealt with heartburn it sounds like for a while.

My goodness.

You know all the tricks in terms of avoiding caffeine the best way possible and to avoid the spicy foods try not to eat late in the evening.

I'm a big advocate of always assessing for the possibility of sleep apnea for people with heartburn.

Sleep apnea will cause you to have difficulty with feeling fatigued and having poor motivation and not having real sharp concentration.

But it's a weird type of symptom of sleep apnea that we sometimes hear about.

It'll be nausea and heartburn and we don't really know why that might be the case.

>> But many people with sleep apnea will have heartburn.

So if you've had any difficulty with snoring or anybody has ever witnessed you pausing in your breathing at nighttime, that's where you'd want to be able to get that assessed overall other types of issues that can lead to heartburn overall from a from a psychiatric standpoint we try to avoid certain medication that will not uncommonly worsen heartburn.

The serotonin medications like Lexapro, Celexa, Zoloft ,Prozac, Paxil these are medications that sometimes will worsen heartburn because 90 percent of the body's serotonin is in the gut.

On one hand if you flare up the serotonin in the gut that can sometimes cause heartburn, diarrhea, nausea.

But keep in mind that the gut and the brain are intricately connected and sometimes people will use probiotics and you can do this on your clinician's supervision if probiotics seem to be a reasonable alternative for you.

But probiotics sometimes will help if people have heartburn that can be responsive to those as well.

>> But exercise particularly aerobic exercise where you're running biking on the elliptical try and trying to avoid the resistance training is the main thing as a psychiatrist I will often hear will help a lot of people outside of the usual medications that can be given.

There's a lot of different medications out there that could be given to decrease stomach acidity and I'm sure those have been discussed with your clinician and the breathing exercises for the purpose of trying to relax and give you a calming calming effect that as well as the exercise are often what will be typically recommended.

Thanks for your call.

Let's go our next caller.

Hello Miguel.

Welcome to A Matter of the Mind.

>> Well, Miguel, you had mentioned you have minor depression and I've been prescribed I'm going to guess bupropion and you're wondering if there should be concern with taking with your blood pressure medication bupropion as a medication.

It's been around since nineteen eighty nine .

It's medication.

It does increase dopamine and norepinephrine.

But interestingly enough, bupropion does not seem to increase the blood pressure for most people.

I think it's because it doesn't profoundly increase norepinephrine the degree that a stimulant might stimulant medications such as Vyvanse, Ritalin, Adderall those are medications profoundly increased norepinephrine dopamine to various degrees and they can increase your blood pressure.

Bupropion does not usually do that and you're wondering about taking a medication called metoprolol metoprolol as a so-called beta blocker and as a beta blocker.

It's basically slowing down the heart rate.

So the blood pressure medication of of metoprolol can decrease the heart rate and calm down the heart rate often help people with anxiety overall whereas bupropion is working in an entirely different mechanism of action.

So that wouldn't be a direct interaction between bupropion and metoprolol in that case because bupropion is working in a little bit more mildly if you were to take a stimulant on the other hand, such as the Adderall or Ritalin type of products.

Yeah, that can give you difficulty with maybe offsetting blood pressure affects about a prelaw but it's always a balance for people if you're getting a really good effect from a stimulant that you're getting too high of a blood pressure.

>> The first thing we'd always want to do is decrease the dosage for you and could consider a medication for blood pressure.

But we don't like to do that.

We don't like to give medications that cause side effects that require other medications to offset those side effects.

We're always trying to find medications that will be effective in what they do but yet not cause side effects.

And again, we don't like to create the need for another medication from side effects.

So in the case of bupropion you could still take that on a regular basis bupropion as a medication and primarily is increasing dopamine norepinephrine in the front part of the brain but it's not increasing dopamine and norepinephrine as much in the middle part of the brain which is where you'd have more difficulty with blood pressure regulation.

So if you increase norepinephrine and dopamine in the front part of the brain, that's the thinking part of the brain.

That's the attention part of the brain.

That's a part of the brain that you use for motivation, judgment, thinking through things and people with attention deficit disorder and depression typically will have decreases in transmission in dopamine and norepinephrine in this left front part of the brain called the called the dorsolateral prefrontal cortex when that part of the brain is decreased in activity you'll have trouble with paying attention to things.

You'll have trouble with motivation.

You'll have trouble with sadness and that's the part of the brain that's being targeted when somebody takes a medication like Wellbutrin or bupropion.

So increasing norepinephrine or opening the front part of the brain would not necessarily increase blood pressure in the rest of the body.

So that's probably what you're getting those that that combination of medications overall there are medications you could take also for concentration to focus in the rare occasion that bupropion was causing you to have higher blood pressure, it might happen and medication is kind of similar but yet it's a little bit different and it wouldn't cause the blood pressure increases would be a medication called Trin Telex or Vaud Occitan.

It's been out for about nine years now.

It's still a brand name medication but talks does increase dopamine and norepinephrine.

It all also increases serotonin has effects on acetylcholine increases histamine which makes the brain more awake and it also increases acetylcholine.

I mentioned earlier that decreasing acetylcholine will cause you to have trouble with memory disturbances, especially if you're over that magic age of 65 years old.

But increasing acetylcholine can actually help you concentrate.

So that's why a medication like 26 is commonly used to help with the speed of processing of information you're able to focus on things more clearly.

It's like giving your brain a little bit more computer speed if you're having trouble concentrating and thinking and many people with depression and for that matter attention deficit disorder will have those kind of problems.

So what we have found with it does not seem to increase the blood pressure at all for people bupropion or Wellbutrin can occasionally but again not as likely to increase the blood pressure compared to a medication like a stimulant.

Now Metoprolol all this primarily blocking norepinephrine as a so-called beta blocker if you need a different type of stimulant.

So if you need a different type of blood pressure medication, you could use a medication like lisinopril.

These are medications that have a different mechanism of action.

They're not directly blocking norepinephrine.

They block a different they have an effect on different type of chemicals.

So that could be an alternative type of blood pressure medication for you.

But talk to your clinician about possibilities for depression if you have increased blood pressure, some medication we actually use to help people with focus and concentration actually decrease the blood pressure themselves.

So if you have a medication like Want Forseen or Clonidine medications that are used with attention deficit disorder, they're used to help with distractibility.

They're used to help with impulsivity, they're used to help with irritability and there are medications that will actually lower the blood pressure themselves.

>> So it's not uncommon that we'll have people take a medication like office a quantity for the purpose of helping with attention deficit disorder or they can help with post-traumatic stress disorder.

They can help with jumpiness and and hipness but they will also decrease the blood pressure so they can get kind of two jobs down with one medication.

>> Bergwall, 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, you may write me over the Internet at matters of the mind all one word at WWE Dog.

I'm psychiatrist J. Oliver and you've been watching Matters of the Mind on PBS Fort Wayne God willing and PBS will I'll be back again next week.

>> Thanks for watching.

>> Goodnight