I'm psychiatrist Jay Fawver, and welcome to Matters of the Mind.

Matters of the Mind is a weekly mental health program where you get to choose the topic for discussion.

So if you have any questions concerning mental health issues that I can answer on the air, you may write me a via the email at MattersOfTheMind - all one word - @wfwa.org.

That's MattersOfTheMind@wfwa.org.

If you're able to do so, you may call or text me during the program.

So let's get started with our first email.

Our first email reads Dear Dr.

Fawver, is Cymbalta a good medication for endometriosis?

Now endometriosis is an obstetrical condition and it involves female parts.

Cymbalta is an antidepressant medication that also helps with pain and it's sometimes used for anxiety.

So it depends on what condition you're treating with endometriosis.

If a woman has endometriosis with pain, Cymbalta can be a good option.

Maybe with anxiety, with depression.

Sure, it can be a good option in a lot of those different areas, but based on what the provider might have decided based on past experience with various medications based on family members treatment responses to medications, Cymbalta might have been chosen, but it's not specifically for endometriosis, but it depends on what kind of condition is being treated.

Thanks for email.

Let's go to our next email.

Our next email reads Dear Dr.

Fawver, There it is.

What can you tell me about Juvmo for a Parkinson's disease?

Juvmo is a medication that got approved by the Food and Drug Administration in late September.

And Juvmo is a medication that somewhat unique for Parkinson's disease.

Basically, Parkinson's disease is a condition where your little substantia nigra, it's a little area right in the middle of the brain, it starts to kind of shrivel up, and it has less activity and releases less dopamine.

And it's thought that it's primarily a condition.

It's due to too little dopamine.

So you have to have enough dopamine for smooth movements.

That way you don't have tremor, you don't have stiffness, you don't have shuffling gate and you don't have a masking of the facial appearance.

So Parkinson's disease is a movement condition.

Now, the traditional treatments for Parkinson's disease for the past several decades have been in Carbidopa-levodopa, which basically will increase dopamine into the brain.

Secondly, they'll use the specific medications that will stimulate two of the five different dopamine receptors.

We have five different dopamine receptors.

If you stimulate dopamine receptor two and three, that can help.

And those have been the medications we've been using such as Pramipexole also used for restless leg syndrome.

And we have Juvmo now that got approved late September.

And it's specifically not selectively stimulating dopamine type two and three receptors but type one and five receptors.

So the bottom line is it's different.

So there's a lot of potential there with it.

Has it been compared directly to the other medications just yet?

I'm not aware that it has.

But it did get FDA approved in late September.

So there's a lot of promise.

And I'm thrilled that we have another option for the treatment of Parkinson's disease.

Thanks for your email.

Let's go to our next email question.

Our next email question reads Dear Dr.

Fawver.

I heard you mention that Covid or the Covid vaccine can cause adverse events similar to traumatic brain injury.

This does not fit the definition of TBI, and I'm concerned that you're discouraging the use of vaccines.

I love the fact that this anonymous viewer that you're disagreeing with me, because this means we can have some discussions about different things, the Covid vaccine or the infection of Covid sometimes will cause a patient to come in and see me and they'll say, ever since I had the infection, ever since I got the vaccine, this, this, this and this happened.

And those different phenomena might be dizziness, difficulty with memory, headaches, similar symptoms as traumatic brain injury.

And my point was that it's similar to traumatic brain injury.

What is a traumatic brain injury?

Well, it's an injury, which means an outside event that involves the brain that is traumatic in the sense that something happens and it causes bad things thereafter.

So to me it sounds like a traumatic brain injury.

But as you correctly assessed, a traumatic brain injury, by definition, is where somebody does have a concussion and they have a jarring of the brain inside the hard skull that we have, and that jarring of the brain will cause various symptoms.

And sometimes people can have post concussive symptoms that lasts for weeks or months.

That's what I'm noticing with some people who have had Covid or the Covid vaccine, even.

And I think that we need to watch for those kind of conditions.

I'd rather say, okay, let's kind of consider possibilities of how we treat this post traumatic event, the traumatic event being the Covid infection or even the vaccine for that matter, and try to do something about it, as opposed to saying, oh, you had the Covid vaccine.

Well, no that adverse events don't exist with Covid vaccine and see in three months, and don't worry about it.

I'm not going to do that as a clinician.

I'm going to try to address what happened.

And if a patient can date back to taking a medication, having an event occur, taking a vaccine, you name it, and then feeling badly in some ways thereafter, I want to possibly treat it so as opposed to treating somebody with a serotonin antidepressant or perhaps with a benzodiazepine for the anxiety they might be experiencing, I'm more inclined to treat them with an anti-epileptic medication if they perceive that they had some kind of event that involved an infection and a vaccine, some kind of an event that thereafter caused symptoms.

So an anti epileptic medication might work better.

So why would I call it something like a traumatic event?

A traumatic brain injury is because that's how I would treat it like a traumatic brain injury.

So with that being said, I think we need to be careful about politicizing or trying to determine medical treatments based on the social climate at the time.

And I've heard that again and again with the Covid vaccine, okay, vaccines can sometimes have adverse events.

That means it doesn't mean we necessarily shouldn't use them.

But my question to you would be, I don't want to prejudge what your particular opinion might have conveyed, but I was wondering, would you have had the same emotional overtone to your passionate response to my mentioning the Covid vaccine might have adverse events?

Would you have had that same kind of emotional response if I mentioned the shingles vaccine having adverse events, hepatitis B vaccines having adverse events, even the influenza vaccine, which I'm going to get tomorrow, having adverse events, I think there's a lot of emotional overtone that came out of the Covid vaccine discussions over the past few years, and my concern is if we don't discuss this and just talk about possibilities and do it back and forth, we're going to miss out on some optimal medical treatments for people.

So I don't think we should make policy based on how we're feeling as a society at the time, what the political climate might be.

I think we should make policy based on observable type of outcomes that we see.

I think we should make medical decisions based on what we've heard from patients and go from there.

So thank you so much for your email and I wish you well.

Thanks for your email.

Let's go to our next caller.

Hello, Rosa.

Welcome to Matters of the Mind.

Rosa.

You want to know, can you be depressed without being sad?

Yeah.

There are nine symptoms of depression or classically mentioned.

Depressed mood is a symptom.

But also you can have simply anhedonia, which is a fancy term for not enjoying things.

Now, most people, when they have clinical depression, will have some sad mood, but some people don't.

And they have the anhedonia, which is difficulty with enjoy things, enjoying things.

Then they have trouble with sleep, appetite, difficulty energy.

They have trouble self-esteem.

They might have trouble with suicidal thoughts and getting along with other people.

So you can have clinical depression without the sad mood.

But most people do have the sad mood going along with it.

But it goes along with a particular question that we use called PHQ-9 It is available at no cost online.

The PHQ-9 gets the discussion started, so the discussion gets started by doing the PHQ-9 Patient Health Questionnaire nine questions.

It's not diagnostic for depression, but generally the higher the score, the more likely you have clinical depression.

And then we go from there and we talk about how long it's been going on.

And we very it's very important that we look at other possibilities in other medical conditions that might cause people to have difficulty with clinical depression itself.

So PHQ-9 is a means by which we will kind of screen people for depression.

Thanks for your call.

Let's go to our next caller.

Hello, Maria.

Welcome to Matters of the Mind.

Maria, you want to know about lead poisoning.

How's affect.

How does it affect the brain and what are the long term effects on the brain?

It does get into the brain, Maria.

It's a heavy metal and it can affect memory, concentration and focus.

It affects various parts of the brain, including the memory center called the hippocampus.

So the long term effects can be difficulty depending on the dosage and how long you are exposed to lead.

But it can cause difficulty in various ways.

And fortunately, we don't hear so much about it now because of the way that lead is being handled in the paints and different exposures already.

Thanks for your call, Maria.

Let's go to our next email question.

Our next email question reads, Dear Dr.

Fawver, I heard that L1-79 can be a breakthrough medication for autism.

How does it work and does it have promise?

L1-79 is the accurate depiction of that particular medication.

It's a schedule.

It's a it's a phase two medication right now, meaning that it needs another phase of complete of completion for testing versus sugar pill or placebo.

And L1-79 is a medication being used specifically for autism, and it's being used for children, adolescents and even adults.

And it's a medication that's considered to be a tyrosine hydroxylase inhibitor.

What the heck does that mean?

Well, basically, when you think about autism, I always thought oxytocin was going to be the target hormone or the chemical that was going to be the treatment for autism over the course of time, because oxytocin is the bonding hormone, and it helps us connect with other people and helps us, helps us social with social connections.

Oxytocin comes from the pituitary gland.

And I thought that an Oxytocin spray or something along those lines would be the main treatment for autism.

But so far that treatment hasn't panned out.

So what they're doing now is they're using medications that are affecting dopamine.

Now, it's thought that with autism you have like this central switchboard here in the thalamus that just gets overwhelmed with stimuli.

People with autism have a hard time handling a lot of different stimuli, such as noise, fast movements, surprises and so forth.

And you have a hard time really assessing the social nuances of other people.

So the treatments for autism historically have been atypical or second generation antipsychotic medications like Abilify, Rexulti, Zyprexa.

Those medications are blocking dopamine in various ways.

They're also enhancing dopamine in the frontal lobe to some degree.

So they're all they're affecting dopamine one way or another.

The the difference between those medications and L1-79, which is a fast tracked medication, L1-79 is a medication that is inhibiting the production of dopamine.

So in other words, if you think about dopamine as being an automobile and it's being manufactured in an automotive plant, okay, so dopamine is an automobile.

If you block the end stage release of the automobile, maybe by government regulations, maybe the company itself says we're going to hold back some.

That's what Abilify, Rexulti, Zyprexa will do or Invega another medication being used for autism.

So we got these medications that are blocking dopamine.

And it's like the automotive company or the government for that matter, blocking the release of automobiles after they've been manufactured.

Okay.

That's been the traditional treatment for autism blocking dopamine or blocking the release of the end product or the blocking the the actual ability to use the end product, for that matter, what a tyrosine hydroxylase inhibitor is doing is actually decreasing the supply chain of dopamine itself.

So it's it's going to delay the manufacturing of dopamine because tyrosine hydroxylase allows this, the production of Dopa.

Dopa becomes dopamine thereafter.

So it is basically decreasing the supply chain itself.

So if you're making an automobile, if you're missing electronic parts here and there, as we saw a few years ago, we weren't able to get electronic parts for automobiles.

So you couldn't manufacture the automobile.

That's what a tyrosine hydroxylase inhibitor is doing.

It's inhibiting the production of dopamine from tyrosine.

And and Dopa then goes to dopamine itself.

So it's it's decreasing the supply line that leads to the production of dopamine itself.

So that's kind of how it's working versus the traditional products for autism where they're blocking dopamine.

What the tyrosine hydroxylase inhibitor was doing L1-79 is actually decreasing the production of dopamine itself.

So I'm hearing it's getting some pretty phenomenal responses already.

It's only in phase two.

As I said, phase three involves a lot more patients longer term assessment.

But it is being fast tracked by the Food and Drug Administration because as many as one out of 40 people now are thought to have autistic spectrum symptoms at least.

So it's something that's very much needed.

And so far I'm hearing that this particular product is fairly well tolerated.

So we're excited to hear about that.

Thanks for your call.

Let's go to our next caller.

Hello, Tom.

Welcome to Matters of the Mind, Tom, you want to know about mood stabilizers.

How do they work in the brain and are they safe long term?

Mood stabilizers usually involve lithium, anti-epileptic medications and antipsychotic medications.

They're all called mood stabilizers.

And basically, as a rule, Tom, mood stabilizers basically will stabilize the mood, similar to a cruise control stabilizing the speed of a car.

So if you put the cruise control on 65 on an hour.

Ideally, that car speed when you're going up and down hill should stay between 60 and maybe 70 mile an hour, but standing around 65 mile an hour, a mood stabilizers should keep you from unnaturally experiencing highs and lows.

And all of them have different uses, different side effects.

We're going to use lithium for people who have experienced classic mania.

Lithiums a salt from the ground - been around for a long time.

And it's a medication that we use, been using for decades now.

For people with certain types of bipolar symptoms, long term, it can cause some difficulty with the kidneys or thyroid, but we monitor for the kidneys or thyroid.

We try to dose the lithium in a controlled release formulation, where you give it all at bedtime at the lowest dosage it possible for mood stabilization.

And for those people, we're hoping they don't have those kind of adverse events.

If they have low thyroid, for instance, sometimes will replace the thyroid from their thyroid gland with exogenous or outside levothyroxine or something they can take on their own.

So there's ways to get around that.

The mood stabilizers that are anti-epileptic, the most popular right now are lamotrigine and maybe Trileptal (oxcarbazepine).

Lamotrigine is Lamictal trade name has a Subvenite trade name.

Oxcarbazepine is Trileptal.

Those are medications that are mood stabilizers that are anti-epileptic m edications.

Tend to be a little bit more tolerable than lithium in many cases, and they can be something that can be used long term as well.

There are many different antipsychotic medications that are mood stabilizers.

They all work in different ways.

There's a second generation antipsychotic medications that are predominantly used.

But boy, over a dozen of them can be possibilities there.

And with antipsychotic medications they have various side effects of their own.

Some of their newer ones are less likely to cause weight gain or metabolic issues compared to some of the older ones.

So we have a lot of options.

And sometimes, quite frankly, we'll combine lithium with an anti-epileptic with or without and antipsychotic medication as opposed to using either of those individually.

So we have a lot of possibilities now for mood stabilization.

Thanks for your email.

Let's go to the next text, Jeffrey from Columbia, Ohio.

You have a question about permanent and long term effects.

After stopping selective serotonin reuptake inhibitors.

And is there anything you can do with those kind of effects?

Well, there are some SSRIs.

If you stop them abruptly, you're going to have a lot of side effects.

You've got to taper down very slowly.

Paroxetine or Paxil being the number one medication of all the SSRIs, is going to give you the most discontinuation symptoms.

And what you'll notice if you stop Paroxetine abruptly, you can have zings or zaps in the in the scalp and the hands or feet.

You can have some lightheadedness, some dizziness.

And for some people can be very troubling.

So with Paroxetine or Paxil, we might not uncommonly taper it off over the course of 2 or 3 weeks and very slowly come down off of it.

You have Lexapro and its parent compound, Celexa, less likely to cause difficulty with withdrawal, as well as Zoloft and even Luvox or Fluvoxamine.

The medication is probably not going to give you any difficulty to speak of with discontinuation symptoms in the SSRI class will be fluoxetine or Prozac.

So if we look at all those as a whole, Paxil or Paroxetine will give you the most selective serotonin reuptake discontinuation symptoms.

Celexa also known as citalopram.

Escitalopram also known as Lexapro, Sertraline also known as Zoloft, will kind of be in the middle.

You can taper off of those typically within about a week or ten days.

And then you have then you have Prozac or fluoxetine.

That's probably not going to be something that's going to give you discontinuation symptoms.

That's something in which we not uncommonly, will abruptly stop because Prozac or fluoxetine will slowly taper out of the system over the course of about six weeks in some cases.

So generally, people will notice that it's slowly getting into the system and they won't have any trouble with it.

Thanks for your text.

Let's go to our next.

Let's go to our next caller.

Let's go to our next email question.

Our next email question is adverse events a euphemism for side effects?

When discussing medications?

I mentioned adverse events earlier.

I'm glad you noticed.

Adverse events is basically something that you'll see in the package, in sort of medications.

And basically an adverse event, quite frankly, is something happened during the drug trial, six weeks, eight week drug trial, even over the course of a year, with long term effects, with long term studies, something happened.

It could be something extraneous, but it might not have been due to the medication itself.

For instance, you'll see adverse events on a lot of medications that said Covid infection.

Well, did the medication cause Covid?

Well, probably not, but it was there.

So if it's there, the researcher has to report it.

If somebody's got a sore throat, if they got a urinary tract infection, even though the medication doesn't seem like it would cause those kind of symptoms, they had to report it.

So an adverse event that you see in the package insert, which is available online for all medications, simply says something happened during the treatment with this medication, but we're not attributing it to the medication.

Side effects, by contrast, is where it will be, where we are using the medications as clinicians for several months, maybe several years.

And we notice, you know, the most common side effects from this medication will be this, this and this and this.

So we'll tell patients proactively they might have certain side effects because side effects are adverse events that are typically attributed to the medication itself based on its mechanism of action based on it commonly being seen in clinical practice.

So some medication as a side effect will have dry mouth, perhaps constipation.

They might have fast heartbeat.

Those are side effects from certain medications.

We point those out to patients.

And with many side effects, they're dose related and their time related.

So with many medications will notice that if we use a lower dosage early on, the side effects are much more tolerable and they go away.

And as we use them over the course of two and three and four weeks, the side effects will typically subside.

Now some people will have side effects, again attributable to the medication that just don't go away.

And they're really annoying okay.

Sometimes we have to look for other options, our ways to offset those side effects.

But side effects are directly attributable to the medication itself.

Adverse events may or may not be side effects, but they were just noticed during the clinical trials, and they're often reported in the package inserts.

And you'll see adverse events there.

But you'll notice in the package insert under the medication, it doesn't say side effects, it'll say adverse events.

And that's because you don't know if the medication directly caused it or not.

Thanks for call.

Let's go.

Our next caller.

Hello, Maria.

Welcome to Matters of the Mind.

Maria, you had a follow up question about lead.

How hard is it to get lead poisoning out of the body, brain and body?

There are binding agents.

Again.

I want to stay inside my lane, Maria, because I don't treat people with heavy metal poisoning myself as a psychiatrist.

So it's something in which you talk with a with an internist and somebody who specializes in heavy metal poisoning to be able to get lead out of the body itself.

But there are binding agents that can actually get these heavy metals out of the body.

Overall.

Thanks for your call.

Let's go.

Next email question.

Our next email question reached Dear Dr.

Fawver I've been taking two tablets of Auvelity every evening, but I've read online that it should be taken twice a day, separated by at least eight hours will work better at twice a day.

It was studied at twice a day because Auvelity is a combination of bupropion and dextromethorphan, dextromethorphan dextromethorphan is the main ingredient.

Dextromethorphan is an old cough medicine.

It's in Robitussin DM.

That's what the DM means.

But dextromethorphan is the main ingredient, Buproprion itself is simply increasing the blood level of the dextromethorphan, allowing it to stay around longer.

When the makers of Auvelity first researched it, they knew that Buproprion had a sustained release an SR formulation tablet that released twice a day, and you separated the pills by at least eight hours.

So they used that formulation for Auvelity, because they didn't know whether dextromethorphan needed to be dose twice a day or once a day.

So they rolled the dice, took a gamble.

Keeping in mind that research studies for new medications often will cost the company up to a billion with a B dollars.

So $1 billion of research money went into this and they said, let's roll the dice.

Let's give this to people twice a day in research studies, and let's see how it does.

It's significantly outperformed placebo actually outperformed Buproprion used by itself.

So it got on the market.

And once a medication gets on the market as clinicians we can use it how we wish.

So it's considered an unapproved use of an approved medication that is not considered to be illegal unethical, immoral none of the above.

Once we get in our hands, a medication for an approved use in any way, shape or form as clinicians, we are allowed to use it as we wish based on our clinical experience, based on data that might be already coming out and based on patient responses that we've seen.

So with that being said, Auvelity is a medication that we found out very early on was difficult for some, not all, but some people to take twice a day.

Secondly, some people who took that morning dosage of Auvelity right off the bat had some dizziness, some woozy, some side effects from it that would last up to an eight hours after they took it so early on, Auvelity has been out for four years now.

Early on we had some patients try two tablets right in the evening at bedtime because the dizziness, the woozy, the somnolence the what they would have would kick in about 20 minutes after taking the pills, but they'd last only about eight hours, so by morning they'd be more awake.

We had many patients noticed that two in the evening worked well for them, and that was okay.

Now it was studied and we emphasize to people.

It was studied at twice a day morning, evening, morning, evening.

Study subjects are paid to be in the study protocols.

Study subjects are monitored very closely week by week over the course of six weeks of treatment typically.

So study subjects are a different kind of population that we'll see in the real world and the real world.

If people have side effects from medication, they say, what else you got?

They want to go to something else.

Study subjects will stay in there because they're getting paid to be in the study itself.

So our patients aren't getting paid to take their medication.

They'll wonder what else they can take.

If they don't like the effects of a particular medication they might be taking.

So we try to work around that.

And with Auvelity sometimes it was being the answer was being just taking two tablets in the evening.

Thanks for your call.

Let's go to the next caller.

Hello, Pete.

Welcome to Matters of the Mind, Pete.

You want to know what happens if you miss a dosage of Clozapine?

Should you double up and take to the next night?

Talk to your clinician about that.

Typically we would not have people do that, Pete.

There are some rare instances of medications that last a long time where you can double up and take to the next night, like levothyroxine, for instance.

It's a thyroid supplement.

If you miss a dosage you can typically take to the next night under your clinician supervision.

Clozapine, you typically would not want to do that because you might have more side effects.

Thanks for your email, and let's go to our next email question.

Our next email question is, does the brain really freeze when you eat ice cream?

Brain freeze.

It's a real phenomenon, but the brain's not freezing.

What happens when you eat ice cream?

The ice cream will go to the hard palate.

The top of your mouth and the coldness of the ice cream will cause the blood vessels just above your hard palate to constrict down.

And now they'll compensate and then kind of blow up and dilate thereafter.

When they dilate thereafter, they will irritate what's called the trigeminal nerve, which comes right out of your cheeks, right up your eyeballs.

The trigeminal nerve fans out, and the trigeminal nerve can cause you a lot of headache pain.

Many people have migraines related to the trigeminal nerve.

What you can do when you're eating ice cream, just to make sure to put your warm tongue on top of your the roof of your mouth periodically to decrease the likelihood of brain freeze.

Thanks for your email.

Unfortunately, I'm out of time for this evening.

If you have any questions that I can answer on the air, you may write me via the email at MattersOfTheMind@wfwa.org.

I'm psychiatrist Jay Fawver and you've been watching Matters of the Mind on PBS.

God willing and PBS willing.

I'll be back again next week.

Have a good evening.

Good night.