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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 the 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 (969) 27 two zero or if you're calling long distance you may dial toll free at 866- (969) 27 to zero now on a fairly regular basis I am 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 e-mail question concerning mental health issues that I can answer online or on the air, you may write me via the Internet at Matters of the Mind at WFYI Big that's matters of the mind at or going to start tonight's program with an email I recently received it reads Durata Fauver I was prescribed Quadri and took it this morning for the first time I was supposed to take 100 milligrams for seven days then 200 milligrams every day.

>> It made me feel very tired and sickly like I had the flu.

Is this normal?

I'm very hesitant to take it again.

>> Should I continue?

Well you can always contact your prescribing clinician but the good news is you've got a very low dosage.

Kalbarri is dosed up to 600 milligrams a day.

It's used for attention deficit disorder and it's specifically and selectively will increase this chemical called norepinephrine if you increase norepinephrine in the front part of the brain in the middle part of the brain, you can be more attentive and less distractible.

So that's how it's supposed to work.

It's the same class of medication as is Strattera also known as Adam Moxa team quaternary is known as the Eloxatin and it's a medication that's going to very selectively increase a chemical called norepinephrine.

It does not need to be taken with food but in your case you're feeling kind of tired.

I'd prefer probably you take it in the evening now that tiredness can go away but here's the key.

>> You know, 100 mg capsules are as low as it'll go if you're having some difficulty can always talk to your prescribing clinician about ways you can get around to a lower dosage one way or another inside the Capitals capsule RBD it is a time release capsule so it's slowly released over the course of a whole day some people will take to be in the evening if they're having that tiredness some people might even take it every other day when they're starting up on it.

>> But quite frankly, one hundred milligram dosage is a dosage that you might give a child between six and 11 years of age.

So adults typically will start at 200 milligrams for the first dosage then go on up to 600 milligrams.

So you're on a very low dosage.

You're obviously very sensitive to it.

>> You likely are a slow metabolism of it which is all the more reason for you to have been given a low dosage.

>> We all have different metabolisms on different on different medications and that's why we do genetic testing sometimes and that can kind of tell us how quickly we metabolize these medications.

So you're likely to slow metabolism on Wilbury Strattera being another option a little bit different medication but they both have a similar mechanism of action.

There's only medications that have been around for decades that will block the uptake of norepinephrine.

They're called norepinephrine reuptake inhibitors and that's what Kalbarri instead of are doing.

But the older medications called dizzier remain inor tripling.

They tend to have more side effects so they give you more difficulty with dry mouth fogginess, haziness, even dizziness and so forth.

So those medications were used back in the 1970s, 1980s and to some degree 1990s and now we're having these newer medications that will increase norepinephrine but they don't give you the side effects of the older medication.

So talk to your clinician about possibilities of staying on the Kalbarri and just take it at maybe even lower dosage if you can get by on that looking at other options.

>> But the first thing I'd suggest you do is don't take it the morning, take it in the evening because that tiredness and that dizziness is hitting you more in the evening.

So I think that's something I could just suggest to you based on what you told me by the email so it'd be a good start.

>> So talk to your primary care clinician or your prescribing clinician about the Kalbarri and see what kind of options you have at this point.

>> Thanks for email.

Let's go to our first caller.

Hello Drew.

Welcome to Mastermind.

>> Do you want to know what is delayed sleep phase syndrome and how do you know if you have so is it associated with attention deficit disorder?

Drew delayed sleep phase syndrome is where you are going to sleep later than most people will.

So in other words it's like your brain is working on second shift when you work second shift it's like you're going to work around 3:00 p.m. or so in the afternoon and you're getting home at 11:00 p.m. Then you go to bed at about 2:00 or 3:00 in the morning.

Then you get up at around 10:00 or 11:00 in the morning.

>> That's delayed sleep phase circadian rhythm and you're exactly right people with attention deficit disorder often will have difficulty shutting their brains off it so they stay up later and that's is kind of a natural phenomenon that many people with ADHD will do and they will make it worse if they go to social media which they often do to try to just relax.

And if you go to social media you'll find that that actually activates your brain and keeps you awake longer.

So many people with ADHD prefer to have second shift shift jobs and even third shift jobs because they will tend to want to stay up later.

They like the quietness of the evening.

They like less stimulation around them because they're less distractible that way and many people with ADHD will get a lot of things done in the early hours of the morning and that's fine if you don't have to get up the next morning.

But the problem can be if you have an 8:00 a.m. responsibility in which you need to attend so that can be a problem.

So delayed sleep phase out syndrome is where you going to sleep later than some people.

How do you bring it back?

How do you normalize it?

Well, we see this not uncommon with with adolescents.

Adolescents need to get up for school at seven o'clock or so in the morning and adolescence their brains as the brains are developing their brains want to have a delayed sleep phase circadian rhythm so an adolescent brain doesn't want to go asleep till about midnight or 1:00 a.m. Not uncommonly that's why some school systems have delayed their start time from seven thirty in the morning maybe to eight thirty in the morning.

>> Some schools out in Idaho I think that's where it all started to actually get started later than that recognizing that the developing brain of a young adolescent will often need to sleep in a little bit.

It's not that they're lazy teenagers just that that's how their brains are made so they can get to bed a little bit later that night and sleep in now how do you artificially bring that delayed sleep phase circadian rhythm back to be a little bit more normalized?

>> You can use melatonin, melatonin a doses of one and a half maybe three milligrams at bedtime will save your brain a chemical signal and it's like a puff of smoke.

>> It lasts for about 30 minutes but melatonin gives your brain a chemical signal to go to sleep.

You have to pay attention to that signal and you have to put down the social media, get away from the television, set away with computer screen and go to bed so the melatonin won't make you real sleepy.

Just gives your brain a chemical signal that you can go to sleep a little bit earlier than what you normally would do now with melatonin you probably want to ease into taking it earlier and earlier if you're going to bed at two a.m. you don't want to all of a sudden start taking the melatonin at 10 p.m. and expect to go right to sleep.

>> You probably want to take the melatonin perhaps at one a.m. for a couple of nights at midnight for a couple of nights and just kind of ease it on back that way.

>> But the most important thing, Drew, is to get up early in the morning because if you continue to sleep in in the morning that kind of throws off your sleep cycle.

>> So if you have a second shift shift job and you don't have to go to bed till 2:00 a.m. and you can get up at 10:00 a.m. that's fine.

But many people have to still get up at eight a.m. or so when they want to stay up late at night.

So for those people you're going to have some sleep debt.

You're going to need more sleep.

You're going to be tired during the day.

You're going to have difficulty with concentration and for some people that can get them fired from their jobs because they just can't function at work because they just can't get to sleep at night.

So there's all different tricks you can use from much sleep hygiene standpoint to try to get to bed earlier.

But from a medication standpoint, sometimes medication like melatonin which I mentioned as a supplement can be used.

But other medications like triacetone gabapentin, low dose occiput these are all non addicting means of helping your brain get to sleep a little bit earlier but you still have to get up earlier because if you sleep in you're going to want to go to bed later that night.

Drew, thanks for your call.

Let's go to our next email.

>> Our next e-mail reads Dear Dr. Fauver, how how does Lamictal work?

>> Elementals also called Lamotrigine and why does it seem to improve the mood since it is used for seizures?

>> Lamictal or Lamotrigine has been around since about the late 1980s.

It's been around for a long time.

>> Lamotrigine or Lamictal is a medication.

It has to be slowly increased in the dosage otherwise you can get this rash on the chest, neck and face and blisters on the fingers and toes is called Stevens Johnson Syndrome looks like a third degree burn and if you increase the doses too quickly and get too high blood level too quickly that can cause you to that particular problem.

So we're always warning people if they see a rash or blisters they need to get off of right away those rather rash and blisters typically will occur within the first two months of taking Lamictal.

So with that caveat in mind, how does it work?

Well, basically it's decreasing a chemical in the brain called glutamate and it's thought that glutamate when you're depressed and when you're under a lot of stress day by day and you can't control that stress glutamates going higher and higher or higher glutamate is the excitatory chemical the brain GABA is the inhibitory chemical.

>> So those two chemicals are the yin and yang.

>> They're like on a teeter totter and they should be balanced out.

If you have excessive glutamate you can have trouble with irritability, depression, anger, impulsivity, excessive glutamates, not good for people.

>> So you want to balance out that glutamate with GABA and the one way you can do that is by using Lamotrigine or Lamictal we will often help people who are giving them Lamictal for the purpose of helping them put up with stuff better the technical term for that is we're trying to improve stress resiliency so we're trying to allow them to tolerate stress better and to not get so snappy and less irritable as they otherwise would do.

>> Now what have we done with those kind of symptoms?

Traditionally for the past 30 years we've been giving medications that increase serotonin and serotonin will give you somewhat of a war of somewhat of a warm embrace.

>> It gives you a calming effect.

It will decrease excessive emotions.

>> It makes you more emotionally dull.

So if you take medications like Lexapro, Prozac, Zoloft, Paxil, Citalopram or Celexa these are medications it will chill you out a little bit and dampen down your emotions so you won't cry as much and you might be a little bit less moody but they'll make many people feel kind of dull for some people they can give them sexual disturbances and even weight gain for that matter.

Well, by contrast, Lamotrigine or Lamictal doesn't affect serotonin.

It mainly affects glutamate and it decreases the excessive load the glutamate may cause.

>> Now that might be confusing to some people because we have these newer medications coming out for depression that are just groundbreaking.

It's bravado or as ketamine has been one of them has been off for about four years now.

It's a nasal spray and we have another one.

It came out last October of 2003 called Although novelty is increasing the normalization of glutamate as well.

>> But these medications increased transmission of glutamate but they do it in a pulsatile manner.

>> If you're under a lot of stress, if you're depressed day by day by day, your baseline level of glutamates too high.

>> So what you want to do with us ketamine or Valide is to give a little pulse increase in glutamate for the purpose of giving your brain a little bit of Miracle-Gro on the little neurons and make it a more fluffy.

So it's like helping little trees branch out there.

They're other different branches and instead of having twenty thousand branches on a tree you have more like one hundred thousand branches on a tree and that's what we do when we give medications that are affecting glutamate in the ways that we wish to do so we're trying to increase the branching on the neurons so it's thought that when you have ongoing depression, uncontrolled stress you have a shrinkage of the neurons and the branches on neurons are becoming less fluffy.

What we're trying to do with the newer antidepressants is to make them more fluffy and it's changed how we treat depression.

>> It used to be that we'd wait six to eight weeks for an antidepressant to go to work.

Now we're seeing effects within a matter of days after giving these types of medication so it's a whole new generation of how we treat depression.

>> Thanks for your email.

Let's go to our next caller.

>> Hello Timothy.

Welcome to Matters of Mind.

So Dr. Farber, Timothy.

>> Yeah.

Enjoy your show.

I don't know how you remember all those details about everything.

It's fascinating to me that you have such a firm grasp of everything.

>> Thank you, Timothy.

I talk about that.

I talk about this stuff every day.

This is all I do.

You ask me about my car engine.

I know nothing about it.

OK, just a curiosity question here I have a very regular sleep schedule had that 11:00 every night and usually up around 6:00 and sometimes I will wake up at four 00 or three, you know and what's curious about it is I may get up and go turn the TV on and fix a cup of instant coffee and sit there and sip on the coffee for a while and I'll go back to bed or into the recliner and when I will fall back asleep and I will have dreams, dreams that I do not have when I sleep through the whole night and this is after drinking coffee I just thought very curious is there any explanation for such a weird thing like that were very vivid dreams too.

>> Yeah you might be sleep deprived Timothy when you have sleep deprivation as you might if you drink instant caffeinated coffee in the middle of night and you're watching television where the screen is kind of waking up your brain and on top of that yeah, you're kind of getting in a recliner instead of going back to bed and you can have some difficulty with sleep deprivation if you do that more nights than not.

So when you have sleep deprivation a few things happen.

Number one, you tend to go into dream sleep a lot faster and a lot more intensely.

So people who are sleep deprived let's say you've you've had obligations at work where you have to stay up all night for various reasons and you just weren't getting enough sleep.

Well, sleep deprivation will cause you to have more intense dreams and second thing will do it'll cause you to go into a deeper sleep and that's why more people will sleepwalk when they haven't had adequate sleep.

>> So sleepwalking is a phenomenon of non REM or non rapid movement sleep.

In other words, it's totally opposite of dreams.

Dreams, sleep and non REM sleep will increase when you're sleep deprived.

>> So I'd imagine timothee based on your sleep hygiene as we call it drinking caffeinated coffee , watching some television at night, sleep in the recliner and going back to bed they might be causing you to crash into a really deep sleep that involves dreaming right when you go back to sleep and force is probably cause more trouble than not night by night because when you're sleep deprived it's not good for you either.

Now dreams are fantastic.

I'm a big fan of people having dreams because when you're having dreams it's firing up this little hippocampus area of the brain here that's helping you retain information.

>> So dreaming is good for memory dreams are very abstract.

>> I always warn people don't read too much into your dreams in terms of what don't try to use your dreams as a means of predicting your future or anything like that.

>> Dreams are very symbolic.

They're very abstract but basically dreaming helps you improve your memory and concentration by firing up this hippocampus area.

And here people with the early symptoms of Alzheimer's dementia often will say they don't have dreams anymore or they can't remember them.

They're not dreaming so much and that's often an indication for the older folks as they're getting these other symptoms of Alzheimer's dementia.

>> Lack of dreaming can be one of the early symptoms people might have now the deep slow wave sleep in which I mentioned where people can have sleepwalking deep sleep, the slow wave sleep also known as non REM sleep is the type of sleep where you just crash in the middle of the afternoon and you're having a power nap and you wake up about ten minutes later and you don't know where you are for about three or four seconds.

That's a deep sleep.

I mean you went into really deep sleep.

It often happens when people are really tired and they're getting a nap or early in the night.

But that part of the that sleep will fire up this front.

This will help this front part of the brain get some rest.

This front part of the brain is called the dorsolateral prefrontal cortex.

This is the part of the brain used for attention span concentration focus helps you keep your mind on things and it needs a rest at night so non REM sleep will help that part of the brain get a rest and non REM sleep will also give your body a rest so you'll feel more energized the next night.

So the reason you need dream sleep is to help your memory and concentration.

>> You need non rem sleep to help you get some help with the focus the next day but non REM sleep is very very important for your overall physical health .

>> So all these different cycles of sleep that go on throughout the night are very important not only for your mental health but also for your physical health when people are more prone to getting sick for various reasons often they have very difficult time getting into these phases of sleep and it's thought that a condition like Vibram Alja is a condition where people aren't getting into a deep sleep and it's thought that due to their not getting into a deep sleep they hurt more.

They ache more the next day they have more sensitivity to pressure and fibromyalgia affects women eight times more than men.

So it's a condition that might have a hormonal relationship going on there.

But with fibromyalgia we think it's somewhat related to lack of deep sleep.

>> So one of the treatments for fibromyalgia will be to get somebody into a deep sleep overall.

>> Timothy, thanks for your call.

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

Our next e-mail question reads Dear Dr. Fauver, I take hydroxyl Zen for my anxiety but I feel as though it makes me feel more sleepy rather than less anxious.

>> What is it what does it what does it make me or why does it make me feel that way?

Hydrazine is an antihistamine and basically it's an antihistamine that is less sedating than Benadryl also known as diphenhydramine.

So you got different ketamine which is the chemical name for Benadryl.

>> Benadryl is often used for sleep and Benadryl will have a strong anticholinergic effect and anticholinergic effect will give you a dry mouth and give you difficulty the fogginess in your thinking with Benadryl they've actually done driving tests on people who took Benadryl at night the next morning up until noon they had a hard time getting around those cones on the driving test so Benadryl can impair your driving the next morning hydrazine is less sedating than Benadryl, less prone to give you the dry mouth, less anticholinergic.

>> In other words, it's safer and more tolerable.

But here's what I often see with Hydroxy and I did prescribe Hydroxy today to low dosage to a person so I do prescribe it but not very often and the reason is it's an antihistamine.

>> It blocks histamine.

If you block histamine it's basically blocking the chemical in your brain that keeps you awake.

>> So as I'm speaking to you right now and as you're listening to me right now, you've got histamine and I've got histamine that's sky high because histamine goes up when you're awake and alert if you block histamine you're blocking down that energizing awakening neurotransmitter and in doing so yeah, chills your anxiety.

>> I just don't like it because it makes people kind of tired and usually it's dosed at twenty five milligrams up to three times a day.

I strongly recommend that we dose it initially at least a ten milligram doses.

Now if you're using it for panic attacks and for more severe anxiety conditions, yeah, you might need higher doses.

I'd prefer to go to some something else that's not addicting such as gabapentin or pregabalin.

We might use something else that is going to help with anxiety is stronger than hydroxy zem but it works differently gabapentin pregabalin work on these little calcium channels and by doing so they decrease the firing of individual neurons.

So if you're having a panic attack or you're severely anxious it'll kind of show you out that way.

So Hydroxy Zeine helps with anxiety by making you less awake which is not always a good thing whereas gabapentin pregabalin will affect the actual calcium channels themselves and decrease the excessive firing that seems to be associated with a severe anxiety panic attacks and that's why Gabapentin and Pregabalin are used for pain very commonly they can be used for seizures but they're more commonly used for pain, anxiety, sleep disturbances.

They can be problematic if you use them with narcotics.

So we don't want to use gabapentin pregabalin with opiates or narcotics because they can amplify the effects of narcotic medication.

>> So you got to be very careful in using it with them.

But they work a little bit differently.

>> They're less likely to make people sleepy and foggy compared to hydroxy and so hydrocodone is a very popularly used medication for anxiety as an antihistamine.

>> But do you just have to remember it's blocking histamine now and doing so if you happen to have allergies?

>> Well, let's knock down as many symptoms as we can with a few medications as possible.

>> If you have allergies and you need an antihistamine anyway and you have anxiety, sure hydroxyl could be fine.

But I'm very cautious and selective on who I might use it .

>> Thanks for your email.

Let's go our next caller.

Hello Lola.

Welcome to Matters of Mind.

>> Lola, you had mentioned that you have a pretty regular sleep schedule but you just don't remember your dreams.

>> That's so common, Lola.

The only way you know if you're having dreams are not definitively would be if you are having a sleep study or you're in a sleep lab and are actually got the little electrodes on your head.

>> You're getting an EEG while you're doing that now are you having dreams or not?

>> Well, if you awaken periodically during the night while you're having a dream, you'll remember them the way our dreams work.

>> Lola our first set of dreams normally will occur about an hour or an hour and a half after we go to sleep at night.

>> So if you go to bed at ten thirty at night your first set of dreams will about midnight.

>> That's how it usually works.

If you're a little bit extra sleepy you might notice yourself dreaming sooner than out as you go through the night you tend to have a longer duration of your dreams and with a longer duration the dreams become more pertinent to what's happening in your day to day life .

So the dreams that you have in the early morning hours after you've already been sleeping for six hours are often something that symbolically pertinent to what's happening in your recent life .

And this is where in psychotherapy if a therapist has more and more of an analytic background is examining the content of dreams, the psychotherapist will often try to figure out how those dreams that are occurring occurring in the early morning hours relate to what's happening in your day to day life .

Keeping in mind that dreams are very abstract, they're very symbolic and we should not plan our lives based on what kind of dreams we're having for that matter.

But you'd mentioned that you just don't feel like you sleep well.

The first thing I'd wonder Lola ,would be are you having any difficulty with snoring and or pausing interbreeding a night?

That's kind of a no brainer number one, if you're pausing in your breathing at night or snoring, that could be a condition called sleep apnea when you have sleep apnea, you're not getting enough air flow to your lungs periodically throughout the night that decreases oxygen to the brain and decreases in your brain.

You're not going to feel very rested the next day.

So sleep apnea is something that's highly prevalent more with people who have thicker necks.

But quite frankly I've seen skinny women have sleep apnea just because they're not structurally getting the airflow through their trachea daytime.

>> So that could be a factor.

>> Another condition is restless leg syndrome if somebody has restless legs or what's called periodic limb movement disorder, they're jump they have jumpy legs at night and for women for instance, all I hear about that when they're heavily menstruating periodically low iron will give you jumpy legs and restless leg.

Some people will be on a serotonin medication serotonin medications I mentioned those earlier Lexapro, Celexa, Zoloft ,Prozac, Paxil these are medications.

>> By increasing serotonin they can indirectly decrease dopamine and in doing so give your restless legs that will cause you to have a hard time getting a good night's sleep so restless legs will be a reason why you might not be sleeping well but you can always talk to your primary care clinician and keep a sleep diary the best you can record when you're going to bed when you get up the next morning what your quality of sleep was like if you did remember dreams are not the best time to really remember your dreams will be when you first get up in the morning, jot them down really quickly because your dreams are kind of like a dry erase board.

They just go away really, really fast.

You forget all your dreams within a matter of minutes after you're awake and so you want to write down your dreams if you really want to make some sense out of them or start thinking about them very intently right after you awake and try to remember what they might have been.

Lola, thanks for your call.

Unfortunately I'm out of time for this evening if you have any questions that I can answer on the air concerning mental health issues, you may write me via the Internet at matters of the mind all one word at WFB dot org I'm psychiatrist GPH offer and you've been watching matters of mind on PBS Fort Wayne God willing and PBS willing.

>> I'll be back again next week.

Thanks for watching.

Goodnight