March 27, 2023

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>> I'm psychiatrist Fauver live from Fort Wayne Indiana.

Welcome to Matters of the Mind now in its 25th year are matters of the Mind is a live call in program where you have the chance to choose the topic for discussion.

So if you have any questions concerning mental health issues, give me a call here.

>> PBS Fort Wayne by dialing in the Fort Wayne area 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 us with an email question that I can answer on the air, you may write me via the Internet at matters of the mind all one word at a dot org that's matters of the mind at egg.

And I'll start tonight's program with a question I recently received.

>> It reads Do it out of favor.

Can you predict if someone is going to become clinically depressed?

>> Well, there's several things you might consider.

Number one, when somebody becomes depressed it's usually a cascade of symptoms that gradually evolve and it's kind of like a growing wave, almost like a tsunami with a tsunami.

>> There's a prediction that a tsunami is going to occur.

You get the lowering of the water level in the sea and it's typically following an earthquake somewhere around the ocean.

Then this big wave, a tsunami comes on.

>> That's kind of how clinically significant depression will will have its onset were first before the Depression hits you're going to have spells where you might have a lot of anxiety and you're worrying about things and you're ruminating about things when that's happening this front part the brain right up here is becoming overactive.

So when you start to brood about things and you worry about things and you overanalyze things and you catastrophically perceive that everything's going to be awful in the future, that kind of gets the rumination the front part of the brain, the very front above the eyeballs that kind of gets that percolating right there.

>> When that happens you typically will have more anxiety and when you have more anxiety this little part of the brain down here called the amygdala becomes overactive.

That's the anxiety anger, the rage center of the brain so to speak.

So the amygdala gets fired up excessively when the amygdala gets fired up it affects other parts of the brain that are affecting sleep.

The reticular formation down here is affected when the amygdala is overactive to the reticular formation is what allows you to get to sleep and stay asleep.

>> Well that becomes disrupted so you start to worry, you get anxious and then don't sleep and you're staying up all night if you don't sleep this left front part of the brain doesn't get a chance to rest at night this left front part of the brain called the dorsolateral prefrontal cortex is the part of the brain that during the daytime allows you to focus and concentrate and maintain motivation and even be able to enjoy things.

This is the thinking part of the brain.

This is the part of the brain allows you to process information it needs to rest at night and that's what it's doing when you're sleeping.

If you're not letting it rest this part of the brain doesn't function.

>> And so while the next day so instead of getting fired up when you need to think and concentrate on things, this part of the brain just can't fire up so well so you can't think clearly enough and because you can't think clearly enough, everything around you starts to have a different perspective.

>> People with depression will often say it's like looking out of a windshield, it's foggy and things just don't have the same kind of brightness and you lack joy in life .

>> You start to give up pleasurable activities that used to be fun and one thing leads to another you give up pleasurable activities.

>> You're not having any fun anymore, no fun anymore.

You get more depressed, you start to have trouble with self-esteem.

You start having trouble enjoying other activities and you don't want to be around people in the more socially withdrawn you get the more you get depressed because we need to be around people to stay at a good mood typically.

>> So socialization helps the brain.

>> So when you hear about this cascade of anxiety leading to insomnia leading to difficulty with concentration which thereby leads to depression, that's often the the wave of tsunami that gets rolling over the course of time.

So when I'm talking to a patient who's having a lot of trouble with anxiety, I take the lack of sleep is being very ,very serious because if somebody's starting to lack sleep and it goes on for a few days in a row, a few weeks in a row, next thing you know it's going to affect the way the brain is functioning now there is actually a biological effect that's occurring in the brain when you have depression it has a toxic effect on the brain itself.

We've known for years especially this area of the brain called the hippocampus that's a part of the brain that's involved in storing memories and processing memories and it's the library part of the brain right here and that part of the brain starts to shrink and it's not that the neurons are dying.

>> It's because the neurons are becoming less fluffy.

Neurons are like trees and like individual trees.

>> They should have a lot of branches and it's thought that our neurons in the hippocampus could have about one hundred thousand branches per neuron.

So imagine a tree with one hundred thousand branches on it.

That's a normal neuron.

When you get depressed those little branches start to shrivel up and you have fewer and fewer branches.

It's kind of like a big storm came through and blew off a bunch of the branches so it's thought that you might go from one hundred thousand branches down to twenty thousand branches on your neurons when you get clinically depressed with fewer branches the hundred billion neurons in your brain just don't communicate so well with each other because each individual neuron needs all these branches to be able to communicate with neighboring neurons and that will be a factor in terms of causing not only depression but as you can imagine long term if an older adult has this shriveling up of the neurons the more likelihood to have dementia.

>> So it's thought that older people when they have depression and puts them at about a four times higher risk for having dementia on down the line so depression can lead to dementia especially for older people for that for that reason .

So when we think about clinically significant depression, we have to think of it as being a neurolaw neurobiological disturbance where your neurons are shriveling up and when we treat depression what we're trying to do is enhance the fluffiness of those neurons and we want to increase this one chemical called brain derived neurotrophic factor which is kind of like the brain's natural Miracle-Gro that helps the fluffiness of the neurons return medications can do that exercise can do that to some degree and talk therapy and psychotherapy if it's successful can do that even though it might not be as prominent.

When I was in my training back in the 1980s we always had people start with counseling and psychotherapy first as a means of addressing depression and anxiety.

>> Now what we will often do is somebody is already having difficulty with a lot of anxiety, sleep disturbances and depression.

>> It's affecting their thinking they're often not going to do that well in psychotherapy until you correct the underlying neurobiological disturbance of the brain.

So nowadays in the 21st century we typically will start people with medication to help them with anxiety, to help them with sleep, to help them with concentration and thereby help them with depression.

And once they come out of that they can start to better address some of the issues they're trying to address in counseling and psychotherapy because there are some issues that might have gotten old Cascade's started just like the earthquake in the ocean started the cascade of the tsunami effects the same thing can happen depression if there are issues in your life that might have started the Cascade, you need to go back to that and deal with that and sometimes that'll involve interpersonal treatment, interpersonal therapy where you're dealing treatment to help you get along with other people might include marital counseling.

It might include issues that at the workplace that might have been problematic for you.

And of course there's the classic psychodynamic therapy where you start to understand why you're reacting to people in today's world as you did as a child.

So it still happens where if you're an adult you'll typically respond in a similar manner as you might have as a child and interactions might remind of childhood experiences and coping skills will sometimes be impaired because you never develop them adequately because you weren't able to have that stress resilience that everybody needs stress resilience is just being able to put up with stuff better and some people have learned to cope in certain situations to deal with those kind of stresses.

>> Thanks for your question.

Let's go to our first caller.

Hello Miles.

Welcome to Mars The Mind Miles.

You want to know what is the difference between post-traumatic stress disorder and see Dasch PTSD PTSD is called complex PTSD complex PTSD is something that's not an official diagnosis but it's something we've recognized for a long time as being there in the background.

PTSD post-traumatic stress disorder often refers to a traumatic event can be sexual abuse, physical abuse, emotional abuse, being in a motor vehicle accident, being in combat PTS usually refers to a specific event or several events that led to symptoms such as avoidance, hyper vigilance where you're always on guard expecting the worst things to happen and avoidance of any memories of those kind of experiences.

So that's post-traumatic stress disorder.

>> It's basically a condition where the middle part of the brain is extra fired up the right in the middle here it's extra fired up.

>> It's spewing out extra norepinephrine which is a chemical derivative of Apennine and so our adrenaline and when you think about the excessive norepinephrine effects that can occur, it makes you jumpy and makes you irritable, gives you difficulty with sleep, gives you nightmares and we've treated PTSD with medications and especially talk therapy for several decades now complex PTSD again not an official diagnosis but it's where you've had ongoing persistent traumatic experiences and in those complex type of traumatic experience that go on and on and on it goes by year after year after year.

It'll often give you later on with unresolved complex PTSD you'll have difficulties, relationship disturbances, mood regulation.

>> You'll be more irritable.

You'll have roller coaster type mood.

I think a lot of clinicians might diagnose somebody with complex PTSD as PTSD is the primary diagnosis and a secondary diagnosis might be borderline personality disorder because ongoing childhood experiences that are very severe and ongoing will often lead to a personality condition called borderline personality disorder where you'll have moodiness and irritability on a day to day basis.

>> You're very reactive to stress and again it goes back to the whole concept of having poor stress resilience and having difficulty with tolerating changes.

People with borderline personality disorder will often have an emotional void a sense of emptiness around them.

They will have a chameleon personality where they will tend to take on the personalities of those around them and it's a phenomenon where they have difficulty with identity and knowing who they are, what they want to do.

They have they struggle with values, identity, career relationships for that reason people with complex PTSD will often have more suicidality and they might try to harm themselves more commonly so they might cut it themselves.

They might intentionally harm themselves.

People with complex PTSD, especially with secondary borderline personality disorder will often have trouble with impulsive.

They will drink, they'll drink alcohol, they'll use substances of abuse.

They will spend erratically.

They'll have sexual encounters that are later found to be irresponsible and they regret having those kind of encounters.

>> So with complex PTSD it's more severe and you're often going to treat more than just the one trauma with if somebody experienced one trauma such as an assault of some type often a type of treatment like eye movement desensitization and reprocessing MDR, it can be very effective for those kind of one time occurrences.

But complex PTSD involves a lifelong encountering of some type of trauma or abusive types of relationships.

So you're often going to have people in much more intensive therapy for those reasons and people with complex PTSD will indeed often require medications to be able to help with the moodiness the irritability and the difficulty of sleep Miles, thanks for your call.

>> Let's go to our next caller.

Hello Julie.

Welcome to Mars The Mind.

Julie, you want to know if two siblings are diagnosed with anxiety?

Is there a higher chance that the same medication will work for both?

Absolutely, positively.

Julie, I'm a big fan of genetic testing.

So with genetic testing it's it's a genetic testing, a test where we can get a couple dozen genes tested from somebody from a mouth swab and from those genes we can determine how well they metabolize various medications.

We can somewhat determine which type of medications might work best for them and with genetic testing we can determine if somebody normally metabolizes a particular vitamin called folic acid also known as vitamin B nine .

And do they metabolize adequately folic acid to eliminate the folate?

So we look at those three aspects especially on genetic testing.

>> However, I find it very, very helpful to know what the family history medical record will be of individuals because if you have a brother, sister, father or brother, father or mother who have experienced similar symptoms as you and they've been on various medications, whether those medications have responded or not responded for your brother or sister, mother or father, it'll be predictive on how you do so.

>> We often will be very curious on how family members have done with various other medications now medications like benzodiazepines, Xanax, Klonopin, Ativan, Valium these are kind of medications that OK, they will typically help everybody feel calmer not a high predictor one way or another.

So if you have a sister who's been on Xanax for 20 years and she's nice and calm, we might not go that approach.

>> But if your sister or you have a brother for instance, who's been on a specific type of medication use for anxiety and it's not addictive, it's something you could use long term, we're going to take that in consideration now keep in mind that on the other side of the pendulum, if you've had a sibling who has not done so well with certain medications, we want to know that too.

>> So when I first see people on their very first appointment, I'm always asking them do you have anybody in your family who's been treated with medications for similar type of symptoms as yours because that's extremely important.

And Julie, as I had mentioned that's to me almost that's as most as important if not more important than actually having the genetic testing itself because it can be a very, very good predictor of response on how family members have done with very various medications and we might be able to indirectly understand that other family members might do well well certain mechanisms of action or they might do poorly with certain mechanisms of action.

Other family members might be very sensitive to certain types of medications which could tell us that OK, you could still take them.

It's just that you need a lower dosage and for those people we'd call them poor metabolisms if we do genetic testing.

>> So it's often interesting that when we hear about how family members have done on various medications and we do get genetic testing, we typically will understand why those family members not might not have done so well because the genetic testing will often affirm what we've known.

If genetic testing was free for everybody I would do it across the board.

But it costs up to four hundred dollars out of pocket with insurance and a lot of cases.

So we will sometimes not have genetic testing available for people but a good number of our patients will have genetic testing done because the nice thing about genetic testing is once you do it it's always going to be the same.

>> It's not like a thyroid test or a glucose test or a lipid test which can change in six months.

Genetic testing will never change.

It'll the very same ten years from now had a person today who I saw who had genetic testing five years ago and I said will get the form.

>> Let's take a look at it and she's going to send it in to us because genetic testing ten years ago is just as good now it's it's always going to be the same.

What's going to change with genetic testing over the next ten, fifteen years will be the number of tests available so the number of tests will grow and will hopefully be able to get a better understanding on how people might do on certain medications.

There's also tests that you might be hearing about for depression, anxiety, dementia for that matter that there's a blood test and it might cost about two thousand dollars or so out of pocket away it costs right now these tests are available and what they're doing they're not just looking at genetics.

They're looking at what's called biomarkers.

Biomarkers are chemical signals inside the bloodstream that can predict to some degree if you're going to get Alzheimer's dementia, if you're going to get depression or anxiety.

>> So they're looking at inflammatory type of signals in the blood itself and some other signals as well.

>> It's not quite ready to be used mainstream but we're hoping that as time goes on as more people are able to acquire these particular tests and do these tests, then the test will be validated and another ten years from now it might be very common to go to your primary care doctor's office, get a blood test for depression or anxiety and maybe get a panel that would even include the dementia biomarkers and just like a lipid test where you see your triglycerides, your LDL cholesterol, your HDL cholesterol in the future we should have these tests where you're looking at all these biomarkers in many of them involve the inflammatory proteins which can predict if you're going to have problems down downstream later in your life with dementia, for instance, it's now thought that much of dementia is related to inflammation and you have these little macro sites, these little these little cells in your brain that are inflammatory in nature and they're creating a lot of inflammation and when people have a condition like dementia ,they have fewer glial cells.

>> Now glial cells are these little cells that are like a pit crew around a race car and you should have about nine glial cells for every neuron with dementia you only have about two .

>> So imagine having a race car pulling into the pit stop and needing this pit crew all around it to change all the tires and and the add gasoline and do some simple mechanical work during the pit stop in off the race car goes you need a certain number of pit pit crew to be able to attend to that race car.

>> The same is true for individual neurons for nourishment and basic maintenance and to cleaning up the junk.

>> That's why Guille glial cells do so with dementia.

It's thought that there's fewer and fewer glial cells around individual neurons so the neurons start to accumulate junk all around them.

>> The trash just doesn't get taken out and that's why you get the high amount of amyloid protein and tau protein that accumulates around the neurons when people have Alzheimer's dementia.

So now we're starting to look at Alzheimer's dementia as being a condition it's often preceded sometimes by years with an inflammatory response.

>> Now it causes inflammation.

We know some things cause inflammation, some things are correctable conditions such as obesity, diabetes mellitus, type two diabetes can give you an inflammatory effect.

People who have head injuries can have inflammation of the brain.

So a head injury is is predictive of having inflammation in the brain later on high blood pressure can damage the little blood, the little blood vessels in the brain, the very, very tiny blood vessels and inflammation can cause people to have difficulty with blood flow and that can increase the risk for dementia as well.

>> So we have to look at all these treatable factors that are associated with dementia and who knows if you're identified as having inflammation that can predict depression, anxiety or even dementia on down the line, the idea would be to try to do something about it earlier rather than later.

There's a lot of research going on for a condition called multiple sclerosis right now and with Ms, people are thought to have a disturbance of the insulation of their individual fibers in the neurons and with the mouse they get this plaque development and one of the ways to possibly prevent it before it starts is making sure that people have adequate levels of vitamin D D as in dog they've done studies in Denmark demonstrating that people out who had lower vitamin D levels because Denmark's in a darker area throughout the year lower vitamin D levels can predict the onset of later on.

So if there's treatable specific type of preventative type of measures we can use if we know it's coming for people that's going to be the idea of using biomarkers in the future.

>> Thanks for your call.

Let's go to our next caller.

>> Hello Bernice.

Welcome to matter Beatrice.

I'm sorry.

Welcome to the mind.

>> Beatrice, you had asked is it legal to apply to prescribe placebos?

I haven't heard Beatrice of placebo is being prescribed for any condition for over twenty years.

>> The last time I remember placebos being prescribed at all was back in the nineteen 90's.

>> Placebos are simply sugar pills.

They don't have any therapeutic value however placebos are used in almost all clinical trials now.

>> Now in the United States we have clinical trials where you have an active medication that you're studying versus placebo and as you go into that clinical trial, you know, as a as a patient, as a study candidate that you may get the placebo, you might get the real drug.

>> So placebos will be used in clinical trials and sometimes a third arm will be used in the clinical trials is called an active active control where it's a medication it would be expected to help that particular condition but it's used kind of like another arm of the study just to make sure the study is valid.

So it's kind of like when we all had those covid test that we were doing all the time during the covid pandemic you had those tests that had the two lines on them if you had covered the study was the test the covid test was valid if the first line lit up that way you knew you had a valid test.

>> If the second line lit up that meant you had covered so two lines but you had covered one line only lighting up just meant that the test was valid itself.

So that's the active control part of the study.

So often you'll get a study drug versus placebo versus an active control and the study drug is compared versus the placebo.

The active control is there just to validate the study was was validated herself.

But Beatrice, I have not heard of placebos being used on a day to day basis for patients because is it legal?

Yeah.

Is it ethical?

I think it's from a it could be a problematic standpoint from an ethical standpoint.

As a clinician I I'm going to try to educate my patients the best I can and if I perceive that they need a fairly low noxious type of medication, I'm going to give them medication that's typically prone to causing very little side effects.

It might not give them tremendous efficacy that some other medications might with more side effects but that's something you'd have to negotiate as a prescriber with patients you negotiate the potential side effects they might have with medication the risks versus benefits of medications, the predictability of how much the medication might work.

But to give the patient a placebo, I think there'd be an ethical issue about that now.

But as I said decades ago it was sometimes sometimes people were given placebos when I was a pharmacist back in the late 1970s, early 1980s I would rarely dispense placebos.

We had a special name for them back then basically it was it was the word placebos spelled backward that was the name of placebos back then.

>> But I haven't seen them used for over twenty years now.

Beatrice, thanks for your call.

Let's go our next email our next e-mail has come in and it reads Dear to the father can you use all Velarde with ketamine or Valide on ketamine?

Both affect this particular receptor in the brain that affects glutamate transmission glutamate is a very excitatory neurotransmitter.

>> The brain it's all over the brain glutamate is what turns a brain on.

Then you got GABA which slows the brain down so you've got this fine balance between glutamate and GABA and if you have too much glutamate you can have seizures, you can have irritability, you can have difficulty dementia too much glutamate is neurotoxic and too little glutamate caused you to be depressed and you can't concentrate and you can't do the things you want to do.

>> So NMDA receptors are affected by both ability and ketamine.

We'll often use ketamine which is a nasal spray.

Ketamine is used IV most commonly but you can use the two together but do so very carefully although it will affect the NMDA receptor a little different place than the ketamine or ketamine will the biggest side effect you might see in use in combination will be a little bit of fatigue so a little bit of tiredness might be the biggest issue.

But so far around the country I'm hearing other clinicians using all which is a new antidepressant with ketamine or ketamine.

Thanks for your email.

Let's well I'll tell you I think we're done for this evening.

Thank you for watching.

Unfortunately I'm we're out of time.

If you have any questions you want me to answer on the air, you may write me via the Internet at Matters of the Mind at WFYI a dog.

I'm psychiatrist Jeff Oliver and you've been watching matters of the mind on TBS Fort Wayne God willing and PBS willing.

>> I'll be back again next week.

Thanks for watching.

Goodnight