Good evening.

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 the chance to choose the topic for discussion.

So if you have any questions concerning mental health issues, you may email me.

If you have the internet at MattersOfTheMind - all one word - @wfwa.org.

That's MattersOfTheMind@wfwa.orrg.

And let's start tonight's program with a text message that I received just recently and it reads I have tried nearly every SSRI selective serotonin reuptake inhibitor and s in re serotonin norepinephrine reuptake inhibitor and have no improvement with my anxiety and depression, I can barely function.

Some of these medications seem to make things worse.

Do I have any other medication options?

Yes, there are many other medication options outside of the medications that merely increase serotonin or serotonin norepinephrine, for instance, there are medications that affect glutamate that can sometimes help in an entirely different way.

Medications that affect glutamate can include Spravato nasal spray.

Auvelity is a pill that can be used, and many times people just need to be reassessed on why they might not be responding.

My goodness, we need to determine if the diagnosis in which retreating is accurate.

For instance, if you don't have anxiety and depression, but whether you have bipolar disorder, you have post-traumatic stress disorder of various types.

Perhaps you have sleep apnea, diabetes, iron disturbances, thyroid disturbances.

We need to sort out what's causing the underlying problems you may be experiencing, and that might contribute to why you're perceived to be so-called treatment resistant to SSRIs and SNRIs.

But yeah, there are many other options out there.

Sounds like you need to get reassessed.

Let's go to one of our several emails we received this past week.

This email reads Dear Dr.

Fawver, I am 48 years old and have issues like previous drug abuse, high blood pressure, and being permanently homebound.

I have had some mental health help in the past, but I'm looking for something new.

How do I find a clinician that is best for me?

Now, considering you could be any part of the state of Indiana, part of Ohio, part of Illinois, and part of Kentucky where we broadcast, keep in mind the best place to start to try to get a mental health referral would be your primary care clinician, primary care clinicians, the family doctors, the internists.

They tend to do the best in terms of keeping up with mental health clinicians in the area, whether it be a psychiatrist, whether it be a psychiatric nurse practitioner, you're homebound, so you might need to find somebody who provides virtual treatment.

That means telehealth, where you can talk to them by your phone and and see them, and they can order things that way.

So talk to your primary care clinician in your area as a first and foremost source of information.

Thanks for your email.

Let's go to our next email question.

Our next email question reads, Dear Dr.

Fawver, can you explain the condition of PDA, also known as pathological demand avoidance?

It seems to be diagnosed alongside autism.

Does it seem more relevant in autism spectrum disorder now compared to the past?

Pathological demand avoidance basically means that you have difficulty putting up with new demands.

In other words, you have trouble putting up with stuff.

We call it resilience in psychiatry.

Pathological demand avoidance is not a true diagnosis, but we see it go along with conditions like autism spectrum disorder, because people with autism spectrum disorder will have difficulty with change and new demands now they'll get really involved with things they might enjoy, and they might become even hyper focused on things they really find challenging and exciting.

And that's why there's often an overlap with autism spectrum disorder, with attention deficit disorder, which will have similar symptoms.

But when you have difficulty with demand avoidance, where you have a challenge, you have too many things kind of bombarding your brain.

What's happening there, looking at the brain itself right here, if you pull the brain apart in the middle, it's the thalamus.

This is like the central operator of the brain.

The thalamus then directs stimuli to various parts of the brain where it needs to be processed.

And if you become overwhelmed, you just can't process that information so well.

People with autism spectrum disorder have that problem.

Many people with depression will have that disturbance.

People with anxiety conditions will also notice that's problematic.

But basically it has to do with having difficulty putting up with stuff.

And again we call it resilience.

We do treat it with medications, but we will help coach people with small doses of new challenges and help people with coping strategies.

Thanks for your email.

Let's go to our next email question.

Our next email question reads Dear Dr.

Fawver, does saffron interact with any antidepressant medications?

I take Effexor and Wellbutrin.

Does saffron actually seem to have a positive effect on mental health?

Saffron is kind of like the Swiss Army knife of supplements for cardiovascular health, for diabetes management, for cognitive help.

It can help to a mild degree, and I think it deserves further study.

It's a it's a spice and it's a supplement.

Around 30mg a day is what many people will take.

But saffron is a medication that has antioxidant effects, anti-inflammatory effects.

It appears to be pro cognitive, so it possibly can help with memory to some degree.

It's been shown to improve blood glucose for many people and even improve lipids.

The question is what doesnt it do?

So it's intriguing.

And full disclosure I have taken saffron in the past myself, and I find it to be very tolerable, but based on its proposed mechanisms of action and benefits.

Yeah, that's something I could certainly recommend for people at 30mg every day, which is the usual dosage.

Does it interact with other antidepressant medications?

Yeah, it can because it has a mild serotonin reuptake effect.

So in other words it can increase serotonin in your brain.

That's where it could interact with Effexor.

Effexor is also known as venlafaxine.

Venlafaxine is about 30 times stronger on serotonin than it is norepinephrine.

So venlafaxine can increase serotonin transmission.

You put saffron on top of that, you can further increase serotonin transmission.

And you could have side effects of serotonin toxicity where you can have difficulty with a fast heartbeat, sweating, tremor, headache, diarrhea.

And it might be kind of uncomfortable, but it's because of the saffron on top of the Effexor.

Saffron on top of Wellbutrin would likely be okay.

So saffron is something that's been used quite extensively over the past years as a supplement.

But it's it's kind of intriguing and I hope that we see further study on it.

Thanks for your email.

Let's go to our next email question.

Our next email question reads, Dear Dr.

Fawver, Caffeine.

I'm practically addicted to it.

I like coffee in the morning and at least a large soda in the afternoon, possibly even more coffee.

Do I need to be wary of any interactions between my caffeine doses and my medications from minor anxiety and depression?

Well, that last question there is very important because if you're drinking caffeine to the point that you get twitchy or you get more anxious or you have trouble sleeping, you're taking in to much caffeine.

Now, a general safe caffeine amount daily day by day is about 400mg 400mg of caffeine.

You can do the math based on the soda that you're consuming.

Coffee per cup maybe has 120mg of caffeine per medium sized size cup, so 400mg a day is considered to be generally safe.

But everybody's different.

And I'll tell people if caffeine keeps you up at night, if you have it after 3 p.m.

or 6 p.m.

or what might be the time frame for you, you shouldn't drink it after 3 p.m.

or 6 p.m., so you need to be the judge on how it's affecting you if you're addicted to it.

There's a couple of questions I have.

Number one, in what way are you addicted to it?

Do you get a feel good effect from it?

Caffeine does two things in the brain.

Number one, it will block adenosine.

Adenosine is like the fumes of the brain as it works all day.

So adenosine is the “A” in ATP that breaks down to ADP and it gives you energy.

So adenosine increases as you get more tired and naturally increases during the day.

And that's why you kind of feel tired and you feel a little bit more cognitively dull.

And you have trouble with thinking as the day goes on.

Use caffeine.

What caffeine will do is knock off the adenosine from the adenosine receptors, and in doing so, it will give you an alerting awakening effect.

It basically fuels the brain that you don't that you don't have any adenosine around, even though you still do.

The best way to get rid of adenosine is by taking a 20 to 30 minute nap.

So a 20 to 30 minute nap is even a better way of getting rid of the adenosine.

But you're using caffeine for in your case, is probably to help you awaken by blocking the adenosine receptor so you don't feel that tiredness as the day goes on.

A second way that caffeine can make you feel kind of addicted to it would be if you feel more joy and happiness from it, that's from increasing dopamine.

So if you increase dopamine, which you can with caffeine, you can feel more joy and happiness.

And the best way to keep that effect of joy and happiness with caffeine is use higher and higher amounts of it.

And that's where people can get in trouble with it.

I'll warn people that if they notice that if they miss caffeine dosing the next day and they get a headache, they feel really grouchy and irritable, and they're actually a little caffeine withdrawal.

That's probably because they're getting too much.

Caffeine normally shouldn't put you into withdrawal.

You might notice if you don't get your afternoon coffee and a cup of coffee in the afternoon is fine for most people.

But if you don't get the afternoon coffee, if you simply feel a little bit more mentally dull or you feel tired, that's okay.

You can have the coffee at that time.

Just being aware.

You don't want to take it too late for your usual needs because you might stay awake at night.

That's the biggest concern we often have with it.

Caffeine can also, as you're likely aware, give you some gastrointestinal reflux where you have heartburn.

So we have to be be aware of any medical effects of the caffeine itself.

But for many people, it's perfectly safe to use up to 400mg every day.

Thanks for your email.

Let's go to our next email question.

Our next email question reads, Dear Dr.

Fawver, what does the process look like for someone in the beginning stages of getting mental help - health help?

Do I get a case manager or a proper support for my appointment?

What parameters are reviewed generally?

Once again, I would say start with your primary care clinician to determine what your needs may be.

Is it more individual therapy?

Do you need coaching on your day to day life circumstances?

Is it more difficulty with a marital conflict?

What kind of things are happening?

Is it work related?

Somebody along the lines there need to kind of coach you and navigate you to the proper clinician.

If it's a case manager, they're going to help you maybe find work, get your life back together.

Case managers are wonderful in terms of coaching you.

If you have a chronic mental illness, this causes you to be significantly impaired.

If you're seeing a psychologist, they're going to look at some certain symptoms and give you perhaps psychological testing to try to determine your diagnosis.

If you're seeing a psychiatrist, they can do a diagnostic assessment where they, too are looking at symptoms and trying to figure out what medications might be best for you, as well as what psychotherapy might be best for you.

So again, start with your primary care clinician as a guide.

You can also contact a local community mental health center.

And they have a wide range of clinicians who can hopefully meet your needs and navigate you to who you need to be seeing.

Thanks for your email.

Let's go to our next caller.

Hello, John, welcome to Matters of the Mind.

John, you had mentioned you have some acquaintances who have bipolar disorder.

What's the percentage of people with bipolar disorder and has kleptomania where people steal things.

Does that go along with bipolar disorder?

Bipolar disorder?

Across the board we're talking about 1% 2% of the population.

Men equals women with bipolar disorder, type one with bipolar disorder type two.

That's more prevalent.

Up to 5 to 6% of the population can have bipolar disorder type two.

So you'll get more of a prevalence with bipolar disorder type two where they have little highs, but then big lows.

With kleptomania, where people steal things, that can that can go in hand in hand with a manic episode where people are flying high with their mood, they aren't sleeping, they're doing impulsive things.

They're talking faster than usual, they're doing things they ordinarily wouldnt do.

And in the context of that, they might lose judgment to the point where they start stealing things.

So that's where the kleptomania can come in.

With bipolar mania, typically, if they steal things well, after a few days, they come down from that high and they have regrets that regrets that they did so.

So especially if they had the regrets that they did so.

And they're not getting a high necessarily from the kleptomania or stealing things that could be from a bipolar manic episode, but kleptomania as itself, without any other conditions.

Yeah, they're getting a high from stealing things.

They enjoy the thrill of the chase where they're getting away with something in their brain.

They get a dopamine rush when they steal something and get away with it, and then they need it.

Like with any addiction, do it more and more commonly.

With bipolar mania, however, that can go along with stealing things as well as part of their poor judgment.

John, thanks for your call.

Let's go to our next email question.

Our next email question reads Dear Dr.

Fawver, how can someone replace and break negative habits?

How can we maintain high dopamine levels that come with comfortable situations that can give us benefits without having the negative habits?

Well, negative habits in general, or habits that typically have consequences that are detrimental to you.

So the first thing you do with your negative habits, you don't want to stop a negative habit because somebody nagging you to stop it.

All right.

You've got to decide yourself.

And the first thing you want to do to try to eliminate a negative habit is to determine yourself, how you why you want to stop it, and what consequences are occurring from the negative habit itself.

It could be something as pulling at your hair, it can be biting at your nails, it can be alcohol use disorder or cigarette use, whatever the negative habit might be.

You've got to identify how it's affecting you and why you want to stop it.

That's the first thing you do.

Secondly, you want to replace the negative habit with something else that's more beneficial for you, something that's going to be more of a healthy habit.

Now, you'd never want to focus, for instance, on saying, I just want to lose 10 pounds as you're as a means of knocking down a fast foods and fatty substances that in your best interest, you want to not look at the outcomes, you want to look at the actual process itself.

So you might want to do away with this particular fast food, this particular ultra processed food, and go one by one and identify what you're specifically going to do in terms of the habits themselves and not focus on the outcomes overall.

But you've got to understand the consequences of why you want to give up the negative habits in which you're referring.

One of the best ways I've ever seen people give up bad habits would be to tell other people, close acquaintances, friends, family, that they're going to give up the bad habits.

So the negative habits such as cigarette smoking.

Okay, you want to give it up.

Number one, think about all the different consequences of why you want to give it up.

But number two, identify how you're going to do it and who you're going to tell about it.

Because if you make yourself accountable to other people, it has a significant impact on your behavior.

So make yourself accountable to other people, announce it to other people that you intend to do this.

And a very significant factor will be from a physiological standpoint in the brain, some healthy habits need to be replaced with something else, but sometimes we need to do so medicinally.

You can have behaviors that replace the bad habits, but you can also medicinally use certain medications to replace what might have been problematic for you.

For instance, a lot of people are having trouble with cannabis or marijuana use, and we're often using a medication called gabapentin to help them get off the marijuana.

So medicinally, we're getting them on gabapentin with the intention of eventually getting them off the gabapentin itself.

But gabapentin is easier to taper than marijuana, and we'll do the same thing with alcohol use and various other substances.

Thanks for your email.

Let's go to our next email question.

Our next email question reads Dear Dr.

Fawver, when did you know you wanted to be a psychiatrist?

Well, to preface, when I wanted to become a psychiatrist and the story behind that, I want to emphasize that I told my kids, I tell my grandchildren this.

I tell this to young adults and adolescents who are thinking about careers, to decide on a career in general.

You want to decide on a career that interests you, and do you like to study for fun?

That's number one.

And you.

Secondly, you want to figure out how you can how you can mold that particular interest and that degree, that level of study in a particular area into something that's going to allow you to make a living.

All right.

So you might be really interested in French Renaissance poetry, but okay, how are you going to make a living with that particular interest?

So that's where you start.

I started with my interest in psychiatry all the way back at middle school.

Yeah, I was a weird little kid, but in middle school, I had a subscription to Psychology Today.

I would clean offices on weekends, and I'd pay for my subscription for Psychology Today because I loved reading Psychology Today, and that was in middle school.

I get into high school, and I find that I have particular interest in biology, math and chemistry.

And I went to a health fair and I was thinking about being a psychologist.

But then at a health fair, I met a pharmacist, and a pharmacist convinced me to go into pharmacy school based on my interest in math, chemistry and biology.

I go into college.

At that point, I went to Purdue for pharmacy school.

In pharmacy school, I met a physician who was our professor for anatomy and physiology.

He was a he was an MD who was a medical doctor.

And I found it intriguing that as a physician, I could put I could implement many of these things I was learning in pharmacy school into into medicine I'd never considered to be in a medical doctor when I was in high school, but I decided to do so in college, and I worked under this physician as a teaching assistant throughout my last three years of college at Purdue.

Once I went into medical school, after I became a pharmacist, the expectation in medical school was for me to go into primary care as a family doctor and internist.

I was going to use all this vast pharmaceutical knowledge I had.

But, you know, I was always interested.

Even in college, I would have read about neuroscience and neurochemistry and the networking of the brain.

I was always interested in how the brain worked.

I would read articles and books about brain chemistry for fun, and that was in college and going into medical school.

So I'm coming out of medical school, and I realized I really like psychiatry for a lot of different reasons.

People told me back in 1983 when I was finishing medical school, that if I went into psychiatry, I'd be wasting my entire pharmaceutical background, because in psychiatry, back in the early 80s, they didn't use many medications.

So I got trained primarily in psychotherapy.

I got very interested in the whole spiritual aspect of psychotherapy.

That was something that was very intriguing to me at the time.

So I go into psychiatry and look what's happened in psychiatry.

In the past 40 years, since I've been a psychiatrist, we've had a boom of different medications that have been available.

We now use regularly over 120 different medications in psychiatry.

So it's been a fascinating journey for me.

And it's it's a journey that allowed me to be able to consult with pharmaceutical companies as an advisor over the course of the years, based on my pharmacy background.

So, yeah, the moral of the story is find something that really interests you and figure out how to make a living doing it.

But the second moral of the story is don't allow opportunities to pass you by because you feel like you're not qualified.

And that includes what I'm doing here on PBS.

When I got offered this position on PBS 28 years ago, the first thing I thought is I'm not qualified to do any broadcasting.

It terrified me to be in front of a camera and talk to people, especially on a live program.

I didn't know what you're going to ask.

And over the course of time, it became very relaxing for me to do it.

But it was an opportunity that I didn't pass up simply because I wasn't qualified.

Don't be afraid to take a chance.

Don't be afraid to pursue those types of opportunities.

So that's how I became a psychiatrist.

Long story short, thanks for your email.

Let's go to an email question.

Our next email question reads.

Does autism have similar symptoms to mental health disturbances like ADHD and anxiety?

And could there be a misdiagnosis between them?

Yeah, ADHD is a condition where people and there's overlap.

If you think of the Zen diagrams, the Venn diagrams, there's an overlap between ADHD, autism and anxiety conditions.

With autism, you'll have difficulty having interpersonal connectivity with other people, and people with autism will have a hard time with mirroring the the emotions of other people in conversations.

We hear about that all the time.

With autism, people have a hard time putting up with stuff.

They have trouble with stress, resilience.

They have trouble with change.

ADHD similar but different ADHD people can have difficulty with paying attention.

They can have trouble with distractibility.

The problem with ADHD, people will get focused on a particular topic and they have a hard time jumping to something else if they're really interested in something.

So with ADHD, they'll have trouble with attention span, distractibility and shifting gears in the case that they need to do so, especially if something's not very interesting or they're or it's not challenging enough for them.

Anxiety symptoms can overlap all of that, because with ADHD it's very anxiety provoking because you're always getting behind.

You're procrastinating.

With autism, you're anxious because of the stress of different things happening in your environment.

You're overly stimulated.

Well, that can all cause anxiety.

So often we will see anxiety components of ADHD and autism, and sometimes you can indeed have autism in addition to ADHD, and we try to sort those conditions out.

Thanks for your email.

Let's go to next.

Next caller.

Hello Lisa, welcome to Matters of the Mind.

Lisa, you want to know about the - have me comment on the Lindsay Clancy case?

The woman who was accused of strangling her children over in Massachusetts.

The short answer on the on that Lisa would be no, I cannot comment on Lindsay Clancy case and I'll tell you why.

I'm a psychiatrist in Indiana.

I didn't evaluate Lindsay Clancy.

I wasn't involved in her case review.

I wasn't involved in the trial.

So ethically, I have no business commenting on Lindsay Clancy case, and I don't like to see it when you when you watch the news and you've got these experts out there making comments, they didn't evaluate her.

They don't know anything about it.

So they need to stay out of that aspect of things.

But I can comment on postpartum depression and postpartum psychosis because they're getting discussed a lot in the context of of her case.

Postpartum depression is different from baby blues.

Baby blues occur with 4 to 5 women after they deliver a baby, so the first two weeks after a woman delivers a baby, the woman can have some sadness, some teariness, a little bit difficulty with sleep, but she's able to function.

That's baby blues, goes away on its own after a couple of weeks.

It's simply a hormonal change that's occurring after delivering the baby.

The progesterone level especially plummets after delivering a baby, and that progesterone decrease.

The hormonal change can make 4 to 5 women pretty depressed.

Then you have about one out of one out of 18 women, and one out of 18 women will have difficulty with, I'm sorry, one out of eight women will have difficulty with having difficulty with more severe depression.

And then you'll have about one out of 18 of those women having what we call postpartum depression.

So about a one out of 18 women will have what we call postpartum depression.

Postpartum depression is where you're not just depressed, but you're functionally impaired.

You can't take care of yourself, can't take care of the baby.

These women have trouble with bonding.

So you'll hear about this to the point where these women do need quick intervention treatment.

We will use antidepressant medications with them, but we now have for the past three years, a medication called allopregnanolone.

It's an allopregnanolone analog that's called Zurzuvae.

The trade name is a that's a trade name.

Zuranolone is the actual chemical name, but it's a chemical look alike to allopregnanolone.

Allopregnanolone is the byproduct of progesterone.

So as progesterone goes down, allopregnanolone goes down.

If you can replace allopregnanolone with a chemical look like such as Zurzuvae or Zuranolone, that can help a woman come out of depression, we'll use that for 14 days, 14 days of treatment.

And we find that for many women, that gives them a very quick turnaround for the postpartum depression itself.

So that's been a very interesting type of intervention for a lot of these women.

Postpartum psychosis, about one out of 1000, one out of 10,000, based on the research.

You see, women will have postpartum psychosis.

These women need an antipsychotic medication.

They have lost touch with reality.

They're hearing voices, not uncommonly.

They're psychotic.

They are not perceiving reality to to be as it is around them.

They often have a history of bipolar disorder.

So bipolar disorder prior to getting pregnant will predict the likelihood of postpartum psychosis later on.

It's a medical emergency.

These women need to be treated right away when they have postpartum psychosis.

So postpartum depression is different from postpartum psychosis.

Baby blues is something that's very common for a lot of people, but that's kind of the spectrum that we will see for women from a mood perspective after they deliver.

Thanks for your email.

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

If you have any questions that I can answer by email, you may write me via the internet at MattersOfTheMind - all one word - @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.

Thanks for watching.

Good night.