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>> Good evening.

I'm psychiatrist Jay Fawver live from Fort Wayne , Indiana.

Welcome to Matters of the Mind now and its twenty fourth year 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 at PBS Fort Wayne by dialing (969) 27 two zero or if you're calling any place coast to coast you may dell'orto 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 Fort Wayne campus.

>> And if you'd like to contact me with an email question that I can answer on the air, you may write via the Internet at matters of the mind all one word at WFA a dog that's matters of the mind at WSW a dog.

>> And I'll start tonight's program with one of two emails that I received this past week.

>> It reads Durata Fovea Is overeating a mental issue?

Are there drugs that can be helpful?

Can counseling help or other kinds of appropriate or are there other kinds of appropriate care?

>> It is considered to be a psychiatric disturbance if you're overeating to the point where you're having health benefits and it's causing significant significant impairment.

Well with that being said, binge eating disorder is a specific psychiatric condition where you are eating to the point of feeling uncomfortably full.

>> You don't really want to eat anymore but you keep doing because it's somewhat of a compulsion to keep eating and many people will do so when they're eating a lot of carbohydrates with carbohydrates it's often difficult to stop binge eating if you start eating protein often that will shut off your desire to eat any more anyway.

>> So there's a lot of different tricks will recommend to people who are having binge eating.

Overeating means going back for a second.

You're going back for thirds.

Some of that is a habit but unfortunately we've got an epidemic of obesity in the United States right now where it's thought that as many as a third of the people in the United States are at least overweight.

So what can you do about it?

Well, you mentioned medications.

We do have some medications.

I would like to be somebody who could formulate a capsule who would take care of overeating in general and allow people to lose weight.

You see the late night television commercials that promise such but unfortunately they don't always pan out.

>> It's been a challenge.

There is a there's a particular hormone called GIRLAND I like to think of Gerlin as being something where it goes up when your stomach is growling so it makes your stomach growl.

>> So Gerlin is something that you are experiencing when you're feeling hungry.

So the girl is increasing.

It's a hormone leptin actually makes you feel false.

Would be nice to find that magic bullet to enhance leptin transmission a release.

>> But what happens is that after a certain number of hours we naturally feel hungry and that's when your stomach starts to growl and that's when you feel hungry.

>> However, if you do something to distract yourself like drinking lots of water doing something else and you miss lunch for instance, you'll notice that even though it might be uncomfortable for 30, 40, maybe 50 minutes or so, eventually two p.m. comes around and you forgot that you missed lunch.

>> What people often fear is that when they get hungry it will get worse and worse and worse and more and more uncomfortable.

>> It doesn't because Gerlin each time you miss a meal or each time you limit your food consumption during that time when you're hungry it tends to dampen and it's rising so you have less and less girl and release as time goes on with each meal that you skip now there is a concept called intermittent fasting that uses this to its advantage.

Intermittent fasting is where you only eat every 18, 20, 22 hours and you have a small window during the day that you eat and you hold to that small window that significantly will impact binge eating and an impacting binge eating it behaviorally kind of changes the hormonal release your inner body so there is no anti gerlin.

There is there is no natural leptin that we can use or what medication do we have available?

Well, medications that are FDA approved for binge eating will be something along the lines of Vyvanse which is less Dixon and dexamphetamine which is a long acting amphetamine product.

So basically as an amphetamine product it suppresses the appetite.

So Vyvanse is one option.

Fifty milligrams of the usual dosage of that you take throughout the day it makes you feel less hungry.

A second option is Fluoxetine also known as Prozac.

It came out in nineteen eighty seven so Prozac has been out now for thirty five years and at doses between 40 and 60 maybe 80 milligrams a day you can get suppression of the appetite not based on just serotonin it's on based on some of the other other characteristics that Prozac will exhibit effects this particular chemical called this particular receptor called Alpha One and if you affect Alpha one it can it can decrease the likelihood of your wanting to eat more and more and more so that's a factor as well.

Topamax Topiramate is an off label or a non-approved for helping with binge eating.

We often find that to be very successful topiramate or Topamax is a medication that is used originally for migraine headaches and is FDA approved for migraine headaches.

But they noticed when they studied patients in the migraine headache trial the ones that tended to overeat tended to eat less when they used Topamax.

So Topamax or topiramate is a medication that started to use for binge eating off label and then it started being used in combination with bupropion or Wellbutrin as a medication combination called Contrave.

Contrave is simply a combination of topiramate and bupropion Wellbutrin and that is an FDA approved medication to suppress the appetite Aleve not Aleve but ALLAI is a medication that has been used over the course of time wouldn't recommend that so much based on our experiences with it but there are other medications that can help people from a medicinal standpoint with binge eating.

>> But I'd recommend that you mainly address it from a behavioral standpoint.

Be very careful eating anything out of a box or bag.

If you eat something out of a box or bag it's going to significantly affect your likelihood of wanting to binge eat.

>> If it's white, don't bite.

In other words, you want to have multicolored type of fruits vegetables if it's white that's suggestive that it's more starch based.

So if it's starch based, potato based, bread based, those type of things they will lead to your binge eating.

In many cases people will tend to binge eat more if they eat late at night and they eat closer to bedtime that kind of throws off their circadian rhythm and many people don't sleep as well when it closer to bedtime.

So I would suggest there's more behavioral approaches out there than there are medicinal approaches for binge eating disorder or overeating.

But there's a few medication we might use.

The first thing that I'm always going to examine when somebody is having difficulty binge eating is look at their current medications because some medications will provoke binge eating.

Some of the so-called dopamine receptor blocking agents also known as the antipsychotics can certainly provoke binge eating.

>> Some of the antiepileptic medications can enhance binge eating and some of the antidepressant medications, even the serotonin medications that you think would help binge eating.

Sometimes they will increase the appetite and increase the weight.

So I always encourage people to track their weight as well as the medication changes they might have made during certain times and see if there's any correlation.

If you notice that you started gaining weight after you started a certain medication, that particular medication even though it might not be highly associated with weight gain for most people can be associated with weight gain for you and has always told people back when I was a pharmacist before I as a physician if you're if if a medication side effect occurs in one out of a thousand people and you're the one you're the one so you have to take it seriously in those cases the key would be to go off the medication under your clinician supervision and see if the weight management becomes more in control.

But there are a few medication will use not uncommonly will recommend people using something like sugar free Metamucil as a means of a simple way of helping you get through that hunger time because sugar free Metamucil that sounds disgusting but goes into your stomach.

>> It swells up these little these little seeds that are upon exposure to water does kind of blow up and they make you feel full.

So it's a way of kind of tricking your body into thinking that you ate wait about an hour or so and next thing you know you don't miss the meal that you thought you were going to miss.

>> But the key is the feeling of hunger is not a medical emergency.

>> Do you do not have to eat despite what we're encouraged to do when we watch the television commercials, you don't have to eat when you have that hunger signal go off, wait an hour or so often that hunger will go away and you can drink plenty of fluids during that time to at least suppress the hunger single by putting something into your stomach that often helps a great deal in itself.

>> Thanks for your email question.

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

Our next e-mail question reads Your daughter forever.

I have been on 40 milligrams of Prozac twice a day so that's eighty milligrams a day recently I had to go ten days without the medication can stop being Prozac for this many days cause a relapse.

Do I need to have the dose adjusted?

Am I suffering from Prozac burnout?

Prozac is a medication that tends to stay in the system to some degree over the course of about six weeks.

>> So if you went off of a for ten days because you're waiting for insurance approval it wouldn't be out of your system.

>> More than about maybe 20 percent would be out of your system by that time would be a really small amount getting out of your system in just ten days however you can feel without lower blood level.

Well, if you're sensitive to Prozac at the higher levels you can start to feel something.

So instead of feeling like you had eighty milligrams a day of Prozac and you might have felt like you're having the blood level of about 60 milligrams Prozac.

So that lower blood level you might have noticed that Prozac does tend to give you an emotional darling effect and it kind of it kind of suppresses the emotions and many people when Prozac first came out in 1980 seven, they complained that it made them feel kind of like a robot.

They didn't feel happy.

They didn't feel sad.

Good things would happen.

They wouldn't feel a lot of joy with that and sad things would happen.

They wouldn't feel real sad.

So they just kind of dampened their emotions.

Now for some people they needed that because they would cry at the drop of a hat and for those people enhancing the serotonin transmission can dampen or kind of dull the emotions favorably.

But you don't want to do so to such a degree that you come across as being apathetic or uncaring when things are happening that are should where you should be showing some sensitivity so the decreased levels of Prozac can give you some depression and bring out more emotions overall.

But there's a delicate balance.

You don't want to feel emotionally dull but yet you don't want to feel depressed.

>> Going higher and higher on Prozac was not always highly beneficial for some people because of the emotional darling effect and you need to take enough of it for it to do you some good.

About one out of three people are good genetic fits for Prozac but about two out of three people are not.

So the other question would be well could you get by on a lower dosage of Prozac with something added to it?

The Prozac burnout phenomenon you to which you referred we used to call it Prozac out.

>> They just met the Prozac work for a while then quit working.

>> Why did that happen?

Well, it's because after you take Prozac for months months in some cases it dampens down the transmission of dopamine.

>> Dopamine is an energizing motivating type of neurochemical and Prozac by increasing serotonin well we'll rock the teeter totter in such a way that the dopamine can go down if dopamine goes down you have that apathetic effect but you also feel like you don't care as much and you can't concentrate and you feel kind of blah.

And for those people we often find a lower dose of Prozac will do better and possibly adding something like Wellbutrin or bupropion to increase the dopamine.

>> Thanks for email.

Let's go next caller.

Hello Barbara.

Welcome to Matters of Mind.

>> Thanks for taking my call.

I'll be happy to take your call.

Barbara, welcome.

OK, by the way I love your shirt.

>> Thank you.

It's got all these little speckles on it sometimes the TV people don't particularly care for that.

>> I kind of do it every now and then to throw them off anyway I've got a question about gabapentin.

I take 300 mg in the evening and then before I go to bed I take Trazodone.

It's just a half a tablet of fifty mg I guess.

And I was wondering can that cause memory loss Barbara the question would be has it caused memory loss for you?

Well I do notice and my memory is getting bad but I'm 84 years old.

>> Oh you're you're still very spry Barbara as we get older you're exactly right past that magic age of 65 there's something about getting that Medicare card or our memory is supposed to kind of go downhill a little bit after that.

But the good news for you, Barbara, that combination of gabapentin and triacetone is actually very favorable for the brain because gabapentin and Trazodone, they work in different ways.

You taking relatively low doses of each.

They work in different ways and they're working they can enhance deep sleep.

Deep sleep is the kind of sleep that we all need as a means of kind of recharging our brain within 30 minutes after we go to bed at night when we're really sleepy we go into deep sleep, the deep sleep will be where if you're awakened you will be kind of confused and need a couple of seconds to kind of figure where you are.

>> That's a good thing.

It's deep sleep and we need deep sleep to be able to allow us to physically get better rested.

Neither the Trazodone or Gabapentin will suppress significantly rapid eye movement sleep REM sleep REM sleep is the is the dream sleep dreaming is good Barbara by chance do you still dream.

>> Oh once in a while.

Good don't be afraid of dreaming even if there are dreams that don't make a lot of sense.

Dreams are great.

I'm always telling people that dreaming is a way of firing up this little hippocampus part of your brain over here.

>> This is the library center of the brain.

This is the part of the brain that shrinks down as you get older and with Alzheimer's dementia it really shrinks down.

But this is the part of the brain that you want to preserve the best you can.

>> How do you preserve brain functioning, getting good sleep and if you need a little bit of Trazodone and 300 milligrams of gabapentin that is perfectly fine.

>> They are not considered to be addictive for sleep.

>> In other words, you don't need to take more and more and more of them over the course of time I've been prescribing both of those medications now for three decades and I just don't see people needing more and more to get the same effect for sleep now with gabapentin you can potentially abuse it roughly three percent based on one study out of New Jersey showed three percent of people can abuse gabapentin and the way you abuse gabapentin is you combine with other things to get a bigger high.

>> Well, if most people don't do that, most people use gabapentin very responsibly and they find it to be very effective long term as we get older, Barbara, we tend to have more aches and pains that awaken us at night.

>> Does that ever happen for you?

Yes, Gabapentin I have a lot of back pain.

>> Yeah.

And that is a natural phenomenon knee pain, hip pain, back pain that keeps people awake and it's a subtle way of us older people to have more difficulty with sleep at night.

>> So Gabapentin decreases the firing of the nerve fibers.

>> It's thought that we'll have more pain if your nerve fibers get itchy trigger fingers gabapentin decreases the itchy trigger fingers of nerve fibers and can slightly decrease pain .

So that's yet another way that gabapentin can be a nice medication for sleep.

But Gabapentin works on little nerve fibers themselves, goes to the brain and will affect this chemical called Gamma Munib Nitric Acid or Gabber GABA is the brakes on the brain gabb slows things down gives you a calming effect.

Trazodone on the other hand works on these so-called serotonin receptors whole different mechanisms of action but by working on serotonin receptors will also help you get into a deep good quality sleep.

But the bottom line is, Barbara, when you're taking a medication for sleep you don't want to be addictive where you need more and more and more of it.

So check for Gabapentin and Trazodone that's they're not addictive.

>> Number two , you want to make sure it's giving you a good quality of sleep.

A good quality of sleep is where you're enhancing dreams or enhancing the depth of sleep ,the deep sleep but you're not suppressing dreams sleep the old medications for sleep way back in the old days would suppress dreams sleep.

We don't want that.

So you don't want to suppress dream sleep.

It used to be a thought that was an advantage of some of the older medications they weren't because it actually compromises your memory and with any sleep medication you want to make sure when you're awake in the next morning you feel awake and and you don't feel lightheaded.

>> So when you find the right combination where you're awakening in the morning and you're not lightheaded, you're not overly groggy, you're on the right track what you do not want to use Barbara you don't want to use the over-the-counter sleep medications that are the antihistamines.

Doc Sillerman which is also known as UNISOM Benadryl diphenhydramine not good medications for anybody over sixty five years of age Rabei over fifty five really for sleep because they can affect your memory the next day I did a driving test years ago for people who took Benadryl or diphenhydramine at bedtime and they slept but when they woke up in the morning there were they thought they're awake but they did a driving test and they were impaired till noon so they had impaired driving until noon after taking Benadryl the previous night.

So any antihistamine if you block histamine receptors it will affect your concentration levels?

No.

Why would you use an antihistamine for sleep?

Well, when we're wide awake as you and I are right now, histamine levels are sky high in our brains.

So when you're awake histamine levels sky high when you're sleeping histamine level goes down.

So if you block histamine you can artificially get the brain to get more sleepy.

We have some of the medications available for sleep now ones that affect or Rexon which is a sleep wake signal and those are more complicated means of helping with sleep.

But your combination of gabapentin and Trazodone is spot on really nice combination.

You know back when I was in pharmacy school back in the nineteen seventies we're always trying to encourage the prescribing of one medication at a higher dosage and one medication only and as the past as the past two decades have progressed we've realized that one medication at a high dosage is not necessarily a good thing.

It's often preferable to have two medications with different mechanisms of action at a lower dosage because any medication will give you more side effects at higher doses the more higher dosage dosage you go on most medications, the more side effects you're going to get so you can keep two medications at low doses but yet you have two different mechanisms of action that will often be advantageous in terms of helping with getting a better outcome in a lot of areas of medicine.

>> Barbara, thanks for your call.

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

>> Our next e-mail question reads Dear Dr.

Favor, how does a psychiatrist determine if someone needs more serotonin, norepinephrine or dopamine?

>> Why does it take several weeks for this this medication to work?

>> Are there ways to get faster relief from depression for the past 70 years the medications that have been used for depression have in one way or another affected norepinephrine serotonin or dopamine.

Those are the three amigos of the neurotransmitters for depression.

They affect the brain regionally and when you take an antidepressant some way somehow it can affect serotonin, norepinephrine and dopamine and in doing so it takes four to six weeks for these medications to go to work.

Now we used to as psychiatrists perceive that we could identify somebody who had more of a norepinephrine depression, more of a dopamine depression, more of a serotonin depression and we can kind of approximate approximate who needs what medication.

>> But more often than not we're just guessing and that's what it amounts to if somebody is really tired they don't have a motivation.

We give them more activating antidepressant like vibrator and telex or Wellbutrin if they're really anxious and antsy we might give them a more sedating antidepressant or our calming antidepressants.

We often use one Zoloft, Mirtazapine or Raemer on at night time can be used for sleep so we will approximate what kind of medication somebody might need based on their symptoms but we're not really good at doing it.

Genetic testing came out about fifteen years ago so it's genetic testing.

We're a little bit better able to determine which type of medication might do better for a person's specific genetics and with genetic testing we can get an idea on what kind of dosage they would need high or low because we are all different in terms of how quickly we're able to break down specific medications.

Some people break down certain medications quickly and other medications slowly and vice versa for others.

So with genetic testing that helps us get back on track.

But for the most part for the past 70 years we've been using medications that enhance serotonin, norepinephrine and dopamine and they take four to six weeks to go to work.

Now how about an antidepressant that can work and change the brain structure within 24 hours?

We're now there we are now getting a lot of medications coming out that are affecting this chemical called glutamate.

>> Now glutamate is the most excitatory chemical in the brain.

It's all over the brain.

The side effects it's 80 percent 80 percent of the brain is affected by glutamate.

>> So glutamate is the excitatory chemical in the brain GABA which I mentioned earlier gamma butyric acid GABA is the brakes on the brains and they are the yin and yang.

>> They have a teeter totter effect where enhancing Gabba Gabba excessively will make you tired and sleepy and and lead to difficult concentration enhancing glutamate.

Too much can give you a seizure psychosis and actually can give you toxicity to the brain.

So we want to keep that balance just where it ought to be.

But if you affect glutamate and enhance glutamate transmission that can relieve depression in 24 hours there's evidence that by specifically affecting glutamate in certain ways you can actually get the little neurons start to grow and out more in 24 hours and there are studies with ketamine or and ketamine for that matter that show that within 24 hours you're already getting not only nerve growth, you're getting outcomes for relief, the relief of depression.

>> I would predict over the next few years we're going to be seeing more medications that affect the effect glutamate and you have a fast onset of action.

They're not addictive fortunately, but they give you a fast onset of action not only in a intranasal a form like Eschaton mean or in IV form like ketamine but also in a pill form.

I think we've got some medications in an oral formulation coming out that are going to affect glutamate and you're going to see onsets of action within a day or so.

The only way do that in the past years was with medications like amphetamines and cocaine and as you're likely aware they make you feel really good for a while but then you crash within a day or so.

>> So not a good treatment for depression.

>> Thanks for your email.

Let's go to our next caller.

Hello Susan.

Welcome to Matters of Mind.

Hello Susan.

Susan, you want to know if there's a relationship between manure's disease and headache and sinus problems?

>> That'd be a great question for an ear, nose and throat doctor.

>> I'm a psychiatrist but as a psychiatrist I sometimes hear about Moneris disease which is a combination of ringing in the ears, dizziness and nausea.

So you get the ringing years, your head feels like it's spinning and you have nausea.

There's the triad of manures disease.

That's not to be an inner ear problem.

It's an ear, nose and throat disturbance.

>> Can people have headaches and sinus problems?

I think from from Moneris standpoint I want to stay in my lane as a psychiatrist and not be an expert on Moneris disease but it's usually an inner ear problem and by all means balance can go along with Moneris disease.

So headache sinus problems can be associated venereal disease but more often than not Moneris diseases where you have ringing in the ears dizziness and balance problems would go along with that as well as nausea.

If you've ever had difficulty with dizziness, sometimes dizziness and inner ear problems can actually physically give you nausea.

The doctor Dr. Mesnier came up with that particular condition as a description and that's why the disease is named after Dr Manier.

>> I wouldn't want a disease named after me though.

I mean that sounds kind of yucky.

So Moneris diseases ear, nose and throat problem for a lot of people.

We hear about these kind of conditions psychiatry just because when people have panic attacks they will often as a part of the panic attack have dizziness, sometimes have nausea going along with that.

So we have to determine is it a psychiatric condition like a panic attack or is it Moneris disease?

>> So that's what we'll refer them to the ear, nose and throat doctors Susan, thanks for your call.

Unfortunate amount of time for this evening.

If you have any questions about a mental health condition you'd like to ask me via the Internet that I can answer on the air.

I mean you may write me at matters the mind all one word at WFYI dot org.

>> I'm psychiatrist Jeff Alver.

You've been watching matters of Mind on PBS for playing God willing and PBS willing.

I'll be back again next week.

Have a good evening.

Thanks for watching.

Goodnight