February 27, 2023

.

,good evening.

>> I'm psychiatrist Jeff Olver live from Fort Wayne , Indiana.

Welcome to Matters of the Mind now in its 25th year, 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 at PBS Fort Wayne by dialing in the Fort Wayne area nine by calling (969) 27 two zero or if you're calling any place else coast to coast you may dial toll free at 866 (969) 27 two 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 concerning mental health issues that I can answer on the air, you may write me a via the Internet at matters of the mind all one word at WFA dot org that's matters of the mind at WFA ECG and I'll start tonight's program with a question I recently received.

>> It reads Dear Dr. Fovea does vaping or nicotine have an effect on the brain?

>> How is it different from smoking?

Is depression associated with vaping while vaping nicotine will deliver the same chemical nicotine to the brain as does smoking cigarets difference will be with vaping and we're going to have some issues there with your inhaling substances that are supposed to be eaten like propylene glycol, vegetable glycerin and those particular chemicals are coating the lungs now with smoking cigarets you're going to have the issues with the aromatic polycyclic hydrocarbons and they have a lot of drug interactions.

They'll actually they'll actually decreased blood levels of a lot of different drugs.

So we have the drug interactions with smoking cigarets with vaping.

>> There's that liquid substance in the vaping that leads to the coating of the lung.

>> So that's my main issue there.

Now once the active drug nicotine gets absorbed into the brain, the brain can't tell the difference between nicotine from vaping or smoking cigarets and the reason nicotine is so addictive is it goes this little area here called the nucleus accumbens which is basically the Las Vegas the brain.

It makes you feel good.

There's a little nicotinic receptors in there and those little nicotinic receptors porn stimulated with nicotine will fire out dopamine and dopamine can help with focus, help with concentration, help with energy helps with mood for a lot of people and actually can in some ways give you a muscle relaxation effect and you might think well that sounds great.

Why shouldn't everybody use nicotine in some form or another?

Well, the problem can be is that when you stimulate those little receptors they want more and more and more and that's why nicotine is so addictive and why so many people have a difficult time stopping smoking because they want to keep stimulating those nicotine receptors.

>> So how do you get off nicotine?

You can go cold turkey but you'll have some withdrawal from our people when they're withdrawing from nicotine will be very irritable and they'll have difficulty with sleeping and frequently have nightmares.

>> And there's this medication called Varanus Island also known as Chantix.

>> When it came out it was thought that Chantix cause nightmares itself.

>> But as they looked at the studies data more in depth, they realized that the patients on placebo also had withdrawal related nightmares.

>> So coming off nicotine itself caused many, many people nightmares.

>> But Chantix will kind of fool that nicotine receptor part of the brain into thinking you're smoking decrease the stimulation on those receptors a little bit but not all away.

In other words, don't totally block those receptors.

You're still able to fire out about 30 percent of the dopamine as what you would fire out if you were smoking cigarets or vaping and using nicotine in that manner.

So there's ways from a medical standpoint to get off nicotine and you can always talk to your primary care clinician about different options because they have lots of different ways of helping people get off nicotine.

Does nicotine cause depression?

It used to be thought that adolescents who smoke cigarets were smoking cigarets as a means of self medicating their depression data coming out over the past twenty years indicate more so that if you start smoking cigarets early on as an adolescent you are more likely to prime the pump in the brain to make you more depressed later on.

So nowadays it's thinking that people who start smoking early on for whatever reason are actually making themselves more depressed later on as opposed to causing them to have as opposed to self medicate the depression when they're adolescents.

But nicotine will increase the dopamine transmission in the brain.

You know that can help with a mood but it can also kind of lay the foundation for being more depressed later on.

>> Thanks for your question.

Let's go to our first caller.

Hello, Matthew.

>> Welcome to Matters of Mind.

Hi Doctor.

How are you doing tonight?

Hi Matthew.

I'm doing fine.

How are you doing?

>> Pretty good.

I got a couple of quick comments, questions and let you answer me bet you bet I didn't subject you brought up about that vaping I stopped at a light.

I sit there and look to the right and somebody is blowing up this huge cloud of smoke and that that stuff can't really be healthy for you, can it?

>> And then another one of these marijuana laws being passed I saw a guy in the gym the other day pulled a little device out and he said it was weed but when he blew it there was no smoke to do.

You smelled nothing.

So I was wondering what he was smoking in my third comment is you just being a doctor, what type of advice would you give the world musclemen for people to just see the world going to and everything just being so loud and being legal now and stuff that the press are all just people who are trying to live right.

>> You know?

Yeah, that's all I got.

That's all I got to say.

Thank you so much Matthew.

Those are great points and you know, for one thing you saw a person that was stopped at a light and you see all this smoke coming out of the car and and vaping.

>> Well, great.

This deep this thick puff of smoke.

But Matthew, it's more socially acceptable.

That's why more people are vaping now because it doesn't have this thick smell that you'll get from them aromatic polycyclic hydrocarbons that you get in cigaret smoke.

So with vaping it's often flavored.

>> It's basically a liquid that has these flavors in it and that's why it's so appealing and that's why it was marketed really toward adolescents to get them to use nicotine in a socially acceptable manner so they didn't smell like the cigaret smoke afterwards.

They might even have a nice pleasant fruity smell about them.

>> So that's what you're seeing.

But what you're doing is you're inhaling a vaporized liquid and it's a thick liquid.

Like I said before, it has glycerin and some of these vaping devices.

>> So the glycerin coats your lungs and there's been a lot of reports more recently of people who have had pulmonary difficulties due to vaping now or 30 or 40 years ago when vaping was just in its infancy it was thought oh, vaping is a very nice alternative for smoking cigarets.

It delivers nicotine in a different way than cigarets will deliver.

But it's not necessarily a safe way.

>> Now you mentioned the marijuana laws with the vaping and everything.

What are these states doing at this point?

If you look at the state of Colorado which recreationally legalized marijuana back in 2012, they're in the midst of a bit of a crisis right now a mental health crisis because adolescents and young adults are using marijuana more regularly.

We're not talking about the marijuana from fifty years ago.

We're talking about more potent marijuana marijuana which with a much higher THC content and because of that people are having more difficulty with irritability, anger, depression in some cases psychosis and what we know about marijuana for these young adults up to twenty four years of age at least is that it suppresses the white matter growth of the brain.

The white matter is the natural insulation on the brain and that allows the neurons, the nerve cells to communicate with each other better.

So people who use marijuana chronically over the course of the years will shrink their brain, especially their young adult years and they have been found to have what would be expected to be lower IQ as they get into their 30s.

>> So why are the states recreationally legalizing marijuana?

A person asked me that today.

She asked me well if it's if the states are legalizing so extensively it must be safe because the states wouldn't want to do anything that would cause US citizens any harm.

Well, you have to remember the states have the motivation that they want to tax the revenue from the marijuana sales so they have a different motivation as opposed to it from a medicinal standpoint.

So there's a lot of motivations that you might find with the marijuana legalization and it has nothing to do with the safety overall.

And you mentioned, you know, as a psychiatrist, what would I advise to people who are seeing the whole world around them falling apart and watching all these different stressful things?

>> Just remember God's in charge.

It's not up to us.

We have a creator and God's in charge everything happening around us and you have to remember God knows that what's happening in this world was going to happen and God knows everything's going to happen in the future if you take the focus off of yourself and feel like you personally have to do something about it and realize that there's a creator that's in charge, that's where you start and from there OK, look at what you can do and what you cannot do and let go of the things you can't do.

You'll hear about something in the news going on in Washington and unless you're a legislator, unless you have some direct accountability for what goes on over there, there's nothing you can do about that and you have to let that go.

Otherwise you're going to have a lot of sleepless nights, sleepless nights lead to anxiety and depression and causes more problems in the long run.

>> Matthew, thanks for your call.

Let's go next caller.

>> Hello, Colleen.

Welcome to Matters of Mind.

Hi, my name is Colleen.

I was calling I have a question about my daughter.

She doesn't live in this state.

She lives in Georgia.

She has not the hyperactive part but she's in her mid 40s.

She used to be on Adderall but since they it's hard to get she is has been off of it for about two months.

She can't the pharmacist down there don't have it and she asked her psychiatrist if she could get something else but those are in low supply too.

>> So I guess my question is what can you do?

>> Colleen, the good news is there are many, many medication treatment options for attention deficit disorder and it's great that your daughter was identified as having attention deficit disorder so that she can do something about it.

>> Attention deficit disorder is basically with a front left part of the brain is a little bit underactive causing you to have trouble with focus and concentration and paying attention to things that aren't very interesting and you're easily distracted.

>> So I often compare attention deficit disorder to needing eyeglasses for your vision.

>> If you have poor vision you can get through life but you'll be squinting you'll be sitting closer to things you'll have to accommodate for that poor vision.

>> You wear eyeglasses, you get their vision corrected and then you can see more clearly and get things and more efficiently.

>> That's the way medication treatment for aid will be.

There are a lot of tricks that people use to try to accommodate for the symptoms such as keeping notebooks, detailed notes, being able to block out outside distractions sometimes with earbuds and things.

But medication treatment can be very effective.

Adderall is one treatment for attention deficit disorder .

It's not the only treatment.

And Colleen, over the past 30 years now Adderall has been extensively used.

I used to prescribe it quite frequently back about twenty years ago but then what happened about ten years ago is a lot of people started using Adderall on the street.

So you had people not using Adderall responsibly for attention deficit disorder.

>> They started using it for energy and then a lot of college students started using it to stay up at night when they neglected their studies throughout the week and now they have a test coming up so they'd use Adderall to stay awake at night.

Adderall is a very has a very potent energizing effect.

That's why people like it to abuse it.

They're using it for energy and you can use it for appetite suppression as well.

But for attention deficit disorder you're not going to get a big energized effect from it.

>> You just you're able to focus better.

So Adderall has been extensively used.

It's to the point where it's been overused.

It was inexpensive.

I'd prescribe a different type of stimulant for patients a few years ago and the pharmacy would tell the patient have Dr. Fauver prescribe Adderall instead will be cheaper.

>> So the pharmacies were actually encouraging this prescribing of Adderall.

So you had this ramping up of Adderall prescribing and that's led to the shortage and I don't know where that's going to go, whether it's going to be off the market in the future or not.

Another medication you might hear about it's in a whole different class Adderall us as a psychostimulant.

It's four different types of amphetamine salts.

>> You'll hear about a medication called Concerta Methylphenidate and methylphenidate is a long is a long acting version called Concerta.

Concerta is now difficult to to find what we do have our other types of long active medication for my patients if they've been on Adderall they typically tolerate going over to Vyvanse very nicely.

>> Vyvanse is a basically dextroamphetamin with little bitty lysine amino acid wing on it.

>> So if you snort Vyvanse for instance you get no effect because Vyvanse has to go to the stomach and then go to the liver and that's where it gets broken down and that little lysine amino acid gets taken off and dextroamphetamin which is one and the main amphetamine salt in Adderall that gets released in the body.

And what's nice about Vyvanse is people don't get a eye on it.

They don't get an energizing effect necessarily from it unless they take a whopping amount and they tend to have about a 12 hour duration on a there's regular Adderall called immediate release Adderall tablets.

They tend to last about four hours.

Adderall extended release tends to last for some people six or seven hours the very most and for that reason people often will have a crash after they come off of Adderall as they're the dosage is kind of wearing off with Vyvanse.

It doesn't happen so much so that's been one of the products we will use.

But the key is, Collene, there's a lot of other long acting products out there available.

The short acting products such as methylphenidate immediate release dextroamphetamin may release might be more difficult to find in the future because that's what people want and that's been in expensive for a long time.

I had a patient one time tell me that she wanted me to prescribe her Adderall because a street value was eight times higher than what she'd have to pay at the pharmacy.

For one thing I'm wondering why are you telling me that you're because you're wanting me to prescribe you Adderall telling me the street value is eight times higher than what she's having to pay at the pharmacy.

So obviously that's not the person who should be taking Adderall but Adderall has a very, very high street value.

Adderall is commonly on the street combined with narcotics and Xanax and that's you think that's a wild concoction but the Xanax will give them a calming effect because Adderall make people anxious and panicky but it'll make them feel good for a while.

But they feel anxious and panicky Xanax calms them down a little bit and then the opiate or narcotic medications like Percocet Torkel or Lortab morphine, codeine those will cause or allow people to have a feeling of bliss.

>> And the problem with the narcotic medications is you keep taking a higher and higher amount of them all of a sudden you shut down your breathing and that's how people die from narcotic use.

But Adderall is one of the most highly diverted medications on the on the streets right now.

So a lot of people are using it and that's why there's such a shortage now there are some after effects of covid pandemic restrictions and the lockdown's a lot telehealth got started and I'm a big fan of telehealth.

I think we should make psychiatric care more accessible to people.

>> So I'm a big, big fan of telehealth but a lot of telehealth different providers irresponsibly started prescribing more and more Adderall and just encourage people to contact them and buy by the Internet through a video visit sometimes by just a phone call they would prescribe an Adderall.

So you had some of these providers out there prescribing tremendous amounts of Adderall during the cold pandemic because the telehealth restrictions were less some I think that with a telehealth visit you should at least have some kind of connection on a regular basis to the office of the telehealth department.

I don't think you should just have some kind of nebulous telehealth provider out there prescribing controlled substances.

I think you should have a bricks and mortar office somewhere where you can establish some kind of relationship with the office staff, with the nursing staff, with medical assistance and with the providers at that particular office to be able to do telehealth.

But some of these telehealth providers are quite shady and they prescribed a lot of Adderall and that had a lot to do with the shortage that we've seen more recently.

So what I'm hearing right now, Colleen, is Adderall might not be available in the future but there are many, many different stimulants out there and you might think well gee, I can't afford the long acting stimulants.

Well, there are ways to afford the long acting stimulants but if worse comes to worst your clinician for your daughter could prescribe a medication like Wellbutrin would be appropriate and you think well gee that's an antidepressant wab or bupropion has been out since nineteen eighty nine .

>> It has about half of the potency of Adderall so it can help with energy and matter of fact it's FDA approved for winter depression when people get tired and depressed and socially withdrawn during the dark days of winter so Wellbutrin or bupropion can be used as an antidepressant that helps with attention deficit disorder even if you don't have depression now that's considered to be off label because the FDA never approved it to be used in that way because it wasn't studied that way originally.

But now we know as we do with many medications once medications get on the market we can use them off label.

It's legal is moral and ethical to do that.

But Wellbutrin is something that would give some effect for aid and probably be better than nothing for somebody who had been on Adderall and no longer can obtain the Adderall, Adderall will be much more energizing and much more alerting much more potent than something be bupropion.

But bupropion is inexpensive now and it's something that does helps to some degree with the reason I often like Adderall the reason I like Wellbutrin or bupropion for patients with ADD will be it kind of sets the foundation because you take it day by day by day but doesn't get out of your system after just a few hours Adderall for many people would make them moody, angry, irritable and they didn't realize it until after they came off of it about six, seven years ago I took all of my patients off of Adderall.

We went to long acting stimulants.

We went to something else and they were angry and they were irritable and they were upset when I told them I was taking them off Adderall but once they got off Adderall they noticed they were less angry and moody and other people noticed they seemed to be calmer because Adderall for some people when it's getting their system they can be more angry and irritable when it's getting out of their system they can feel more withdrawn and it just causes mood swings that was really problematic for people.

So Colleen, I think for some people it might be somewhat of a blessing that they won't be able to obtain Adderall right now because it'll coerce them to maybe go to another treatment for attention to attention deficit disorder.

>> There's the stimulant medications.

There's the medications like Wellbutrin which are used for other purposes.

There's medications such as Kalbarri which is a medication.

It specifically increases norepinephrine as an alternative to the stimulant medications.

So it's not addictive and a lot of different options are out there calling.

So encourage your daughter to look for other options if for if a physician doesn't know of any other options besides Adderall the she really should see somebody else because there's at least 15 20 different possible treatments for AIDS outside of Adderall at this point.

>> Colleen, thanks for your call.

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

Our next e-mail question reads Dear Dr.

Favor, my family doctor has been able to help me through some relatively minor bouts with depression.

I've been prescribed europium.

I just mentioned that that's Wellbutrin and it's been effective though I still occasionally suffer though my family doctor has been excellent.

How do I know I should see a specialist specialist would be somebody like myself a psychiatrist, a family.

>> Doctors can do a marvelous job with prescribing antidepressants and getting you trying different things different family doctors have variable levels of comfort with different antidepressant medications bupropion being one many family doctors are familiar with these serotonin medications like Lexapro, Zoloft, Prozac.

It's been out for a long time and sometimes they'll go another step and they'll use some of the more recent medications like Trin talks and more recently Velarde.

So there's a lot of different options out there.

>> What it comes down to is if you feel better but not well yeah you might want to see a specialist if you're not quite getting over the hump now the good thing about Wellbutrin is it doesn't work on serotonin so you're not going to get that emotional darling effect that some people don't like.

You're not going to have weight gain.

You're not going to have sexual disturbances.

So there's a lot of advantage with your being on the program.

But bupropion is indeed dosed up to 450 milligrams a day.

I saw a patient today who had been on 150 milligrams a day for a few weeks from the family doctor and said it didn't work well.

Only about one out of four people are going to get a really good effect from one hundred fifty milligrams.

>> So immediately I took her up to 300 milligrams.

I said let's give this a try for another couple of weeks and we'll go from there.

So there's other options that can be done.

I always want to make sure when somebody is better but not well that they have normal thyroid glucose, normal iron, they don't have sleep apnea.

I'm looking for these other kind of medical conditions that can contribute to somebody not responding adequately to an antidepressant medication.

>> But then if we've covered all those different areas and you're not quite where you want to be, your primary care doctor can prescribe a medication, has Wellbutrin or bupropion in it.

It's called Sovaldi although it came out in October 22 and it's a medication that has bupropion in it.

But the main purpose of bupropion is to increase is other chemical that's been around since nineteen fifty nine called dextromethorphan dextromethorphan a cough medicine.

It's been around for a long time but dextromethorphan when you take it for a cough gets in your system breakdown within an hour into a chemical called Dextra or fan it sounds just like it but it's Dextra fan the extra often does not help with depression dextromethorphan does so you want to keep the dextromethorphan hanging around longer and you do that by adding a little bit of bupropion.

So bupropion just simply keeps the dextromethorphan hanging around longer.

What you're doing there is not just affecting dopamine and norepinephrine as you would do with bupropion.

You're also starting to regulate glutamate and glutamate is an excitatory chemical in the brain and I've treated over 300 people with all Valide now and I'm finding that it's helping with enjoyment with different things ,with interest, with enthusiasm for life excitement and it's helping them in ways that other medications have not yet been able to to help.

Now we've used ketamine for about four years now it's ketamine.

>> We'll do the same thing with acetylene.

It's a nasal spray and you have to sit in an office where they use ketamine, sit there for two hours during the treatment to be monitored and you're treated with us ketamine twice a week for the first month, once a week the second month then once a week or ever every other week thereafter.

>> So it's ketamine can be used but all Valide does some of the similar type of things that Istomin will do only it's oral and it's not as potent is not as strong as it's ketamine.

But for many people they find some pretty dramatic benefits with it.

So there are other options outside of bupropion.

The first thing I wonder with bupropion if you feeling better but not well or still have a lapse of depression, I'd wonder have you gone up on the higher dosage now some people can't go beyond 150 milligrams a day because he'll get more irritable and impatient and a little bit more antsy and anxious.

>> So if you can't go a higher amount you might want to stay at 150 milligrams a day and add something else or change over to ability.

But the first thing I want to do is consider going to a higher dosage if you're not if you've not been to 300 milligrams a day on bupropion or even 450 milligrams a day bupropion going higher on bupropion for many people will give them a better effect and sometimes we'll add something to it.

It depends what kind of residual symptoms you might have.

I'll have people rank on a scale of zero to 100 percent zero being that aren't getting any benefit at all from the medication 100 percent.

They're knocking it out of the park.

They feel great.

They feel fantastic.

If they score above 50 or 60 percent I'll probably leave the medication they're already on alone and add something to it.

So it's kind of comes down to how often and how intense those little bouts of depression might be.

>> Thanks for your email.

Unfortunately I'm out of time for this evening if you have any questions concerning mental health issues I can answer on the air.

You may write me via the Internet at matters of the mind all one word at WSW org I'm psychiatrist Jeff Offer and you've been watching matters of the mind God willing and PBS willing.

>> I'll be back again next week.

>> Thanks for watching.

Goodnight