March 13, 2023

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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, 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 our local studio at PBS Fort Wayne at (969) to seven to zero or if you're calling anywhere.

Coast to coast you may dial toll free at 866- (969) to seven to zero now on a fairly regular basis we are broadcasting live every Monday night from our spectacular PBS Fort Wayne studios which lie in the shadows of the Purdue Fort Wayne campus.

>> And if you'd like to contact with an email question that I can answer on the air, you may write me a via the Internet at matters of the mind all one word at WFB Egg that's matters of the mind at WFB Egg and I'll start tonight's program with an email I received this week.

>> It reads Director Fovea is there a shortage of ADHD medication?

Is there a risk of dependency in starting these medications?

What's the difference between Vyvanse and other generic generic medications?

>> There is indeed a shortage of the short acting ADHD medications and here's what happened.

>> We're coming up pretty soon on our three year anniversary of the covid restrictions where people were told to stay at home and during that time the telehealth restrictions right by the government were basically unleashed so the clinicians could indeed communicate and treat patients by initially the telephone and then as video access and the platforms became more available ,they were allowed to see people more on video.

Now we have this technology in place for the past 15 or 20 years.

It's just that there were so many restrictions that didn't really make it convenient for patients.

For instance, previously patients would have had to go to a doctor's office to be able to do a video visit.

It kind of defeats the purpose patients wanted to stay home and be able to do the video visits from the comfort of their homes and that's what happened during the covid pandemic restrictions where people were forced to stay at home.

>> More often than not we're allowed to do more telehealth that has continued over the past three years and during that time there were a lot of advantages of the telehealth.

But one of the disadvantages was that some clinicians around the country were basically seeing individuals for telehealth purposes and they were prescribing very haphazardly stimulant medications so you could live in New Jersey and you could have a telehealth visit with a doctor in California and readily get a stimulant from the doctor in California sight unseen where that doctor preferentially might give you a stimulant that is a short acting stimulant and that's what people would often abuse and divert on the street.

>> They wanted the short acting stimulants and that's why the short acting stimulants such as Adderall which is based on individuals with whom I've spoken who have diverted medication on the street Adderall is the drug of choice of all the stimulants on the street and I was told that individuals on the street when they're selling medication back and forth they like Adderall and they like Xanax bars, the Xanax bars or the alprazolam two milligram tablets that come in bars you can cut them in pieces and that's been a preferential combination for a lot of the people who are abusing those medications.

So you can imagine if more and more stimulants are getting prescribed online, there's going to be a shortage and there's a particular shortage with these short acting stimulants.

Now the difference between the short acting stimulants and long acting stimulants will be that with a short acting stimulants the people who use them will get a bit of a high.

>> They'll get extreme energy.

They'll get a pulse of a chemical called dopamine and to some degree norepinephrine.

And when they get that pulse they get a surge of energy.

That's what they were looking for .

That's what they want when they abuse the medication.

Many people who abuse Adderall and the short acting stimulants ,they're not using it for attention deficit disorder.

They're using it for energy and ironically they're using Xanax as a means of slowing them down.

Why would they use a medication to speed it up and another medication to slow them down?

It's because they like the energizing high from the similar medication but then they feel anxious and they get panicky so they need to take a medication to slow them down and they also need medication to help them sleep at night because they're taking such a high dosage of a stimulant medications so the stimuli medications can be safely used particularly in the long acting versions because the long acting version won't give you that pulse of energy.

>> They won't give that pulse of dopamine and norepinephrine.

>> That's what causes people to get addicted and that's what people will often crave and they need a higher and higher dosage of the medication to be able to get that effect.

Adderall extended release for instance, is commonly used at twenty milligrams a day for ADD and that's all people need when people are using for energy they'll say well it doesn't work anymore so the doctor will prescribe a higher amount and a higher amount and a higher amount.

Next thing you know people are up to 90 to 120 milligrams a day which I've seen in my practice so what I do is I get these people slowly off of it.

They won't go into severe withdrawal.

They'll feel really tired and all they'll complain they're feeling more depressed when they're not on it.

But you need to replace it with something that's going to be safer.

But what people will often notice when they're off of the stimulants, when they're using them at these high doses for energy they'll notice they're not as moody, they're not as irritable and they feel calmer overall.

>> Vyvanse is a medication that has a little lysine amino acid on dextroamphetamin to so dextroamphetamin is a stimulant when you put a little ICN amino acid on it, if you snort it, if you inject it nothing happens if you take it by mouth it goes to the stomach and in the stomach it starts to break down where that little amino acid comes off as the medication goes to the liver and then you get a slow release over the course of ten to twelve hours of the dextroamphetamin.

So that's why Vyvanse is a preferred medication by a lot of us who are treating ADHD simply because it slowly releases throughout the day.

>> People don't get a high on a lot of people don't use Vyvanse so much on the street because they don't get that high.

They want the short acting stimulants.

They give them that pulse of dopamine, that pulse of energy and that's why they get in trouble with it.

So stimulants can be very safely used.

They're very effective for the treatment of ADHD symptoms.

It's just that we use higher and higher amounts of them for energy.

That's where you get in trouble.

Thanks for your email.

Let's go to our next caller.

Hello Peter.

Welcome to Matters of the Mind .

Peter, you had mentioned that stressful events will set off depressions.

What can you do so it's less likely to have a depressive episode?

Well, Peter, why do some people have depressive episodes depress sadness is a normal emotion as is happiness, anger, anxiety, apathy.

Those are all normal emotions.

We should have these normal so-called vicissitudes of emotions throughout our days because when stuff happens we should react to them with emotions.

>> Otherwise we'll be emotional robots and we don't want that.

>> So depression when it becomes a clinically significant depression, Peter, is where for at least a week or two you're noticing that you're not only having a sad mood, you're having trouble with enjoying things.

>> You have a low self-esteem.

You don't have energy as you ought to have.

You're having sleep disturbances.

You're having appetite disturbances and you might even have thoughts of death.

>> You have all this these different symptoms going on their day by day by day and it's unnatural.

>> It's like having a dark cloud hanging over your head and it just hangs there.

So what causes depression?

It's about 30 percent genetic so it does run in families more so with women than men.

Women are twice as likely to have depression than men has something to do with her estrogen and progesterone going up and down prior to reaching menopause.

So women are at higher risk for depression but people who have depression for a lot of other different reasons among which will be stressful like of life events if you've had past stressful life experiences you're more likely to have depression later on when similar experiences occur unless you've learned coping mechanisms now there's a slippery there, Peter, because if you've learned coping mechanisms and you've encountered and overcome past stressful events and improves and strengthens your stress resiliency which makes you more likely to put up with stress in the future.

So if you learned to cope with past stresses because you've encountered them in the past, it's less likely you'll have future depressive episodes if you encounter those kind of stresses.

So the first thing you need to do, Peter, is to figure out OK, what kind of things might set you off in depression and what kind of stressful events might you need to learn to overcome and how can you cope with those kind of stressful events?

>> How else can you cope with depression itself?

Peter, it's always very important to have a purposeful, meaningful daily activity and in their life it's important to be able to serve others.

People will often rely on their faith to be able to serve others, treat others as they want them to treat themselves and in doing so be able to always reach out and keep the focus off of yourself.

It's when people becomes very preoccupied with taking care of their own needs and thinking about themselves.

That's where they are more likely to get depressed.

I often tell people the the best thing you can do when you're depressed is what you often don't want to do and that's where you try to take care of other people and you socialize and you get out and about and you try to interact with other people.

Doing enjoyable activities will often keep you out of a depression, Peter, because when people get depressed they often will give up pleasurable activities and it's a vicious cycle because the fewer pleasurable activities you do, the more likely you're going to have difficulties with finding pleasurable activities to find enjoyable.

>> So as you give up pleasurable activities you're more likely you're more depressed and that's often the first thing people do when they get more and more depressed.

They don't do the things that used to be fun.

It's very important to stay physically active when you're depressed so maintain some kind of physical activity.

Typical recommendation is do something 20 to 30 minutes a day to get your heart rate going up a little bit but just have some kind of physical activity on a day to day basis.

Five days a week is usually adequate but some kind of physical activity and that can include something as simple as taking a quick walk.

>> You might do ten minutes in the morning, ten minutes in the afternoon afternoon, ten minutes in the evening.

It doesn't have to be all at once but some kind of physical activity will also keep you out of depression a lot of times now.

Yeah, we use medications for people with depression but those are people with who are experiencing clinically significant depression where the front part of their brain is shutting down in its activity and that is the reasoning and the logical part of the brain.

So when that part of the brain starts to shut down, you start to ruminate, you start to dwell on things and the thinking part of the brain will shut down where they're ruminating part of the brain right up front above the eyeball will actually increase in its activity.

So when you get depressed the ruminating part of the brain, the doubting part of the brain really gets fired up.

Another part of the brain that gets fired up when you get depressed is this part of the brain over here called the amygdala.

>> It's the anxiety, fear and anger part of the brain and that's why many people when they get depressed they'll get more anxious and they'll get more irritable and angry.

It's an old truism that men will typically get more angry and irritable when they get depressed whereas women will show it through their emotions with having more crying episodes.

But it's all one of the same from the brain's perspective.

It's just a matter of how you demonstrate and exhibit the actual symptoms themselves when you have depression because that's left front.

Part of the brain up here is shutting down the dorsolateral prefrontal cortex.

That's the logical thinking part of the brain when it's shutting down you have a slowing of the processing speed of your brain so you can't process information as quickly as you did before.

So many people when they get depressed they'll wonder if they have a new onset of attention deficit disorder.

Well, it seems just like that.

But with attention deficit disorder by definition it has to start back when you're a child and it's a day to day phenomenon.

We've always had the difficulty with attention span and focus.

>> Many times when we treat depression we'll see the erm the concentration the processing speed, the distractibility all improve because of depression will cause all those types of symptoms.

Now people will often ask well is is it the stress, is it a biological disturbance, what's going on.

Do I need counseling during therapy.

Do I need medications 30 years ago everybody had counseling first that's where we started with the treatment.

>> Everybody had counseling or psychotherapy first.

So there they were always there was always a search for the reason for the underlying depression itself and there might be some stressful life events but some people just woke up on a Tuesday morning or a Thursday and they just were depressed and there was no reason for it.

They were just depressed.

That's where the neurobiology of the brain was taking over.

>> And there's this fine balance in the brain between a chemical called glutamate and GABA Glutamates excitatory gabber is inhibitory and they need to be and find balance.

Dopamine, serotonin and norepinephrine will fine tune that balance.

But those that that balances is really what you need to have to stay out of depression.

So when that neurobiological disturbance occurs you'll notice that you get unnaturally depressed out the blue you feel more depressed.

So we're always trying to correct that imbalance, know there's different ways to do it from a medical standpoint.

>> We have medications we're looking for underlying medical reasons like the low thyroid diabetes, low ion sleep apnea.

Those can throw off the neurobiological imbalance, throw off the neural neurobiological balance such that you'll feel unnaturally fatigued and tired, depressed and you can't think so we want to correct that.

We sometimes we'll look at a diet gluten intolerance is a real phenomenon.

Some people have trouble with wheat and they will predictably notice that when they have wheat and then on people who are especially prediabetic they'll have trouble when they have too much carbohydrate or sugar intake they'll notice it affects their mood.

So we'll look at those kind of medical conditions overall but medications will be for the purpose of affecting serotonin, norepinephrine and dopamine but with the newer medications are directly affecting glutamate such as ketamine as ketamine also known as bravado and a newer medication by name of all varieties.

These medications are affecting glutamate directly and they're getting everything in finer balance so stress can impact depression itself.

And when you think about stress, Peter, we're talking about a change in your environment.

So a stress is just a change in your environment and every day we're enduring enduring stress.

It's actually not a bad thing.

You don't want to have the same day repeated every day.

That could be a nightmare.

There was actually a movie made about that with Bill Murray called Groundhog Day Hog Day where he was experiencing the exact same circumstances every single day and you don't want that either.

You want to have differences in your day to day activities.

You want to have those changes but those are stresses they become problematic when the stresses become so difficult to manage that you become overwhelmed and it affects your mood and the cascade will often be you initially get anxious and you start brooding about something that anxiety and that brooding in that ruminating will lead to insomnia.

When you start having trouble with sleep on down the line that's like your battery not getting your getting recharged adequately in your brain.

So the next thing that happens is you don't reason very well because we need good sleep at night to recharge this thinking part of the brain when you sleep at night this thinking part of the brain is at rest when it's at rest you have dreams and that's where dreams will come from this front part of your brain is resting at night and you should normally have dreams when you're getting a good night's sleep you wake up, you feel refreshed and you're able to fire up that part of the brain and think through your life's challenges as the day gets started.

So you want to have this left front part of your brain working to be able to think through your difficulties otherwise simple stresses will feel overwhelming for you and the next thing you know you're ruminating, you're brooding, you're having more anxiety, you're having more anger and the cascade starts.

So you want to try to take care of the anxieties in life .

>> Look at the the pros and cons of different circumstances you're enduring understand what you can tolerate, understand what you can change but accept what you can't and then try to get a good night's sleep.

>> Now we're coming you're getting into basketball season with March Madness.

Everything going on right now.

So we have to remember it's got to be very careful when you stay up late at night watching the games because if your sleep gets gets a little bit off track and your circadian rhythms become disturbed, it'll cause you to have more difficulty with possibly getting back on track the next day and you're more prone to having depression there.

So try to get to bed the same time every night, try to get up the same time every day and that in many cases can help you keep the circadian rhythms on track and keep you in good sleep hygiene.

>> Peter, thanks for your call.

Let's go next caller.

Hello and welcome to Matters of Mind.

And you wondered about your children.

You'd mentioned a throw a fit when you limit their phone and screen time.

>> Well, good for you and that's what you ought to do.

How much time with electronics is appropriate for young children?

Well, and I'm going to give a disclaimer here I don't treat individuals under sixteen years of age but I can give you a few tips here generally you don't if I tell you a certain time somebody's going to disagree with it because somebody's going to say it's less than that.

>> It's more than that.

I think you have to be the judge is the mother of your children to determine what's the appropriate time for them and how long it should go on.

But I think you're on the right track because you're limiting their screen time to a certain amount now phone is screen time.

>> Yes, it can be educational but when it becomes problematic when the children are getting more irritable, when they can't be on it, that can be a problem.

>> It's important for children to be able to have physical activity.

>> I still think those are things that we used to call books that have papers in them and everything.

You get them at the library books are still good so so books are still very effective for learning because children have to actively read and look at the books with screen time.

The problem with the with the electronics is that the screens will flash at them and they'll feed them information very quickly and sometimes I think can actually provoke them into expecting a lot of excitement while they're learning and with the algorithmic effects that we have now with social media.

>> Social media knows what you're watching and social media will keep feeding you what you want to watch and what what it thinks you need.

And there are some phenomenal algorithms that are in the computer that basically keep track of everything you're you're watching.

It'll time you by the seconds if not milliseconds how long you're on certain sites and it keeps feeding you information to keep you on that particular line.

I had a friend of mine who went to Las Vegas this past week and he reminded me that in the casinos they pump in oxygen and they don't have any clocks on the walls and there's no windows.

So if you think about that, OK, they're pumping in oxygen to keep you a little bit more energized but there's no clocks on the walls if there's no clocks on the walls and there's no windows, you don't know how long you been there.

>> You start to lose track of time.

That's what the screen time is trying to get you to do to not keep track of time and forget what you're doing and the longer you're on a particular site they're trying to figure out how to keep you on that site.

So having a clock, having a timer is a good place to start and for some parents they find that fifteen minutes is long enough.

Others will limit it to thirty minutes, others to an hour but be aware that the longer they stay on unless it's educational at some point long line there they need to be learning.

>> They need to be doing their their schoolwork and they need to be learning but if they're on the screen time with well computer games if they're on there for activities that are not really enhancing their cognitive development, it could be a problem.

So as a parent it's important for you to realize how long they can tolerate certain amounts of time on the screen based on what they're watching to try to get them involved in some kind of educational activities, things that will actually enhance their learning over the course of time.

>> And thanks for your call.

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

>> Our next e-mail question reads Dear Dr. Fauver, are there antidepressants that can cause excitability or irritability?

My son has had a change since he started taking his prescribed in depression medication.

>> Yeah.

I mean if you have a noticeable increase in irritability or excitability after taking an antidepressant medication, it might not be that just that antidepressant.

>> There's been 17 newer oral medications, oral antidepressive medications that have been developed since nineteen eighty seven.

>> So they've been a lot of them coming out over the course of time and if they cause irritability or anxiety you might not simply want to go to another one.

You might need to consider something along the lines of a mood stabilizer because if an antidepressant increases excitability or irritability you might have to have a dosage.

So the first thing you always want to do is take a lower dosage.

But I'm always wondered in the back of my mind if that excitability or irritability might not be uncovered.

An underlying bipolar spectrum condition now bipolar spectrum to condition is where you will have mood swings naturally you might not know it's there until you actually provoke the mood swings with something I can antidepressant medication.

So it's like having a tank of gasoline sitting in your garage is sitting there perfectly happy until you light a match close to it.

Then it explodes.

That's how an antidepressant can evoke manic episodes in people who might be prone to mania who didn't have yet now they might get it eventually but they didn't have it yet.

>> Many people with bipolar disorder will initially have a depressive episode after a depressive episode after a depressive episode.

>> Well, how do you know they're going to eventually develop mania or hypomania for that matter?

>> Well, the first thing you ought to do is take a look at their family history.

If somebody has a first family history of bipolar disorder father, mother, brother or sister, you always want to consider the possibility they might have a manic episode.

But if you do see the excitability or irritability occurring with an antidepressant medication, especially with adolescents and young adults up to twenty four years of age, the first thing you want to do is drop the dosage, reconsider if they even should be on an antidepressant at that time and possibly add a mood stabilizer to it.

There were studies that were done on the older antidepressants way back in the 1990s on adolescents and it was found that some of the adolescents had suicidal thoughts and behaviors after they took certain antidepressants especially Effexor and Paxil.

For some reason those the two antidepressants at that time that were most likely to evoke suicidal thoughts and behaviors.

Well, Effexor has a very short duration in the body.

It's not bound to proteins more than about thirty five percent whereas most of the rest of the antidepressants are bound by like ninety five percent of proteins.

So Effexor gets in the bloodstream very, very quickly and it's thought that that might have been one of the reasons it was prone to evoke suicidal thoughts and behaviors.

But then Paxil, Paxil when you miss a dosage it gets out of your system very quickly and you get an antidepressant discontinuations phenomenon going.

So that might be a factor there.

But the bottom line is what all these children and young adults had in common who had suicidal thoughts or behaviors.

What they had in common is they had irritability, excitability, racing thoughts, impulsivity decreased need for sleep.

To me that sounds like bipolar spectrum condition.

So it's not that the antidepressant medications were causing suicidal thoughts and behaviors.

>> It was that they were evoking an underlying bipolar spectrum condition that was already there but they were just kind of revealing it and you were seeing it with these young adults and children.

Thanks for your call.

Let's go our next caller.

Hello, John.

Welcome to Matters of Mind.

John, you want to know what is an intrusive thought and how does it differ from an impulsive thought and intrusive thought is a thought.

>> You know, it doesn't make any sense but you can't get it off your mind.

It's often considered a obsession where it just ruminative you've got a stupid thought on your mind and you can't get it off your mind.

>> It might have something to do with morals, sexuality, aggression but it's a thought it has no business being there but you can't get it off your mind and it's really from this front part of the brain here being a little bit overactive and it's kind of spinning its wheels and you've got this thought that shouldn't be there instead of going away like a puff of smoke it just stays there.

That's also known as an obsession and impulsive thought is more likely a thought that comes your mind that you do indeed intend to carry out such an impulse if is where you're thinking of doing something and without any thought without thinking it through you're ready to go.

So an impulsive thought is a thought that usually leads to action with very little thought.

>> John John, thanks for your call.

Unfortunately I'm out of time for this evening.

>> If you have any questions 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 a dot org I'm psychiatrist Jeff Alver and you've been watching Matters of the Mind on PBS Fort Wayne God willing and PBS willing.

I'll be back again next week.

Thanks for watching.

Good night