Good evening.

I'm psychiatrist and welcome to Matters of the Mind.

Matters of the Mind is a weekly mental health program where you have the chance to choose a topic for discussion.

So if you have any questions concerning mental health issues, you may email me via the internet at the address MattersoftheMind - all one word - @wfwa.org.

That's MattersoftheMind@wfwa.org.

And if you're able to do so, you may call me or text me during the program.

So let's begin with tonight's first email question.

Our first email question reads, Dear Dr.

Fawver, How does progesterone hormonal replacement therapy help with menopausal symptoms and mood?

I recently had to stop it because my genetics showed a possibility of breast cancer, where you might have also been on an extrodiol, or estrogen hormone replacement therapy.

Progesterone basically goes down, down, down, down after you are reaching the perimenopausal and the menopausal days when progesterone goes down, its active byproduct is called allopregnanolone.

Allopregnanolone is a byproduct of progesterone.

Allopregnanolone is like the brain's natural Xanax.

In other words, it keeps you calm, helps with happiness.

It does a lot of good things naturally.

So imagine as allopregnanolone is going down, as progesterone is going down during the perimenopausal and menopausal days, you're going to have trouble with anxiety, sleep, concentration, and if you add a little bit of estradiol to progesterone, that can give you some benefits.

So progesterone has a lot of good mental health benefits during the perimenopausal and menopausal days.

And people often use the bioidentical progesterone.

I'm going to stay in my lane and not make any particular recommendations.

All I know is that when people are coming off of progesterone and estradiol, okay, they have to come off of them for various reasons.

And I get that.

So what I'm trying to do as a psychiatrist is try to help them adapt to coming off of them.

So in other words, when somebody's coming off of hormonal replacement therapy that contains progesterone, for instance, they will often have a lot of anxiety.

They'll have trouble sleeping a horrible time sleeping.

They'll have trouble with feeling irritable and more depressed.

So what I will often do is try to temporarily offset some of those difficulties that they're having from the with from the withdrawal of progesterone.

Now during postpartum depression, after a woman delivers a baby, the same phenomenon can occur only times ten, where it's occurring very abruptly.

Postpartum depression is manifested by progesterone, also decreasing abruptly.

It's occurring during the first month after delivery.

And it's not just baby blues where a woman feels kind of sad for a couple of weeks after delivery.

Postpartum depression is where a woman cannot bond with her baby.

She can't sleep, she's feeling miserable, and she's feeling horribly depressed.

Now we have a medication to address that particular progesterone withdrawal.

That medication is called Zurzuvae, also known as the Zuranolone.

Zuranolone is a chemical lookalike to allow pregnenolone.

So your brain thinks it's looking at our pregnenolone when it's actually looking at Zurzuvae or Zuranolone.

So we have a way of treating postpartum depression in that manner.

And you do it over the course of two weeks.

So with postpartum depression, the offsetting of the progesterone withdrawal is accomplished over the course of two weeks with perimenopause and menopausal symptoms that might be over the course of several months, for that matter.

So talk to your clinician about different options at this point in terms of treating the depression and anxiety that might be there now that you're coming off of progesterone.

Thanks for your email.

Let's go to our first caller, our first text, hello, Fred from Fort Wayne.

Fred, you want to know could we use clonidine for anxiety?

Could we use use clonidine for anxiety.

Clonidine is a medication has been around since the 1960s, I believe.

It was originally used as a blood pressure medication.

It's called an alpha two agonist.

In other words, what it does, it'll decrease blood pressure, a chemical cousin to clondine and is guanfacine.

Clonidine has been around for a long time to lower the blood pressure.

It's very effective at lowering the blood pressure, but it will have effects on norepinephrine in such a way that it can decrease anxiety as well.

We use clonidine in psychiatry to decrease anxiety and distractability associated with post-traumatic stress disorder, as well as associated with attention deficit hyperactivity disorder.

So for both for PTSD and ADHD, those were clonidine and will frequently be used.

We will use it for the purpose of mitigating the symptoms of anxiety.

Clonidine can be a very effective medication for decreasing nightmares, for instance, with people who have post-traumatic stress disorder because with PTSD, what appears to be happening is a disturbance in this left front part of the brain where basically there's a disturbance in norepinephrine.

Clonidine can correct that.

So instead of having nightmares, you can normalize that.

Many times people were given clonidine at bedtime.

Biggest side effect to clonidine will be over sedation and blood pressure drops.

So if you have normal blood pressure for instance, and you take your blood pressure can drop fairly abruptly.

So those are the main concerns we have about it.

But clonidine can use can be used for symptoms of anxiety.

Thanks for your text.

Let's go to our next caller.

Hello, Michael.

Welcome to Matters of the Mind.

Michael, you want to know about hormonal replacement shots for prostate cancer.

What do they do for the brain itself?

Basically what they are doing, Michael, is they are blocking testosterone receptors, and testosterone receptors are responsible for prostate cancer.

In my experience, some people will have moodiness from that, because basically what you're getting is a abrupt blockade of male hormone receptors.

And with abrupt blockade of male hormone receptors, you feel you feel like you're really low on testosterone really fast.

So what most people will notice, for instance, will be lack of energy, lack of motivation, lack of initiative, lack of enjoyment with things.

They'll have a lot of overlying symptoms of depression, and we'll try to over oversee those kind of symptoms of depression and offset them with various medications to help people come around, because if you have prostate cancer, you want to have all the best hormonal shots you can possibly get to try to get the prostate cancer in good control.

Thanks for your call.

Let's go to our next email question.

Our next email question reads, Dear Dr.

Fawver, what is schizoaffective disorder and what are the long term effects of it?

Schizoaffective disorder basically is a combination of the condition of schizophrenia with bipolar disorder or depression on top of it.

So schizophrenia day by day by day with a mood disorder condition on top of it.

So here's how it works.

You have schizophrenia that has the average onset of 16 years of age for a male, 24 years of age for a female.

So it's a condition that starts in the early adult years.

Schizophrenia is characterized by difficulty with social anxiety, difficulty with autistic symptoms where you have trouble processing information and picking up social cues, but most importantly, with with schizophrenia, you'll have difficulty with having lack of initiative, you'll have trouble with enjoying things, and you can have certainly hallucinations where you're hearing things that other people can't hear, and delusions where you have fixed false beliefs and you're thinking and concentration can be very disorganized in such a way that you have a hard time following people and they have a hard time following you as you're speaking.

So schizophrenia is a day to day condition it will have with, if untreated, various symptoms associated with it.

Schizoaffective disorder means you have schizophrenia day by day by day, but on top of that you can have manic highs where a few days here, a few days there, you don't need to sleep.

You're more impulsive.

You have racing thoughts.

Just on those days you're doing things and saying things you ordinarily wouldn't do or say.

And then you can.

You can possibly have depressive symptoms if they're very prominent over the course of a couple of weeks where you have difficulty with enjoying things, you have trouble with social withdrawal, sleeping all the time so you can have the highs or the lows with schizoaffective disorder, but with schizoaffective disorder.

The reason why diagnostically it's important that we get it right is number one, you do need an antipsychotic medication with schizoaffective disorder.

But number two, not uncommonly, you might need something for the depressive symptoms and or the moody symptoms where the highs and lows.

So sometimes we'll give people an antipsychotic medication as well as a mood stabilizing medication and use those in combination.

So the reason we talk about schizoaffective disorder versus bipolar disorder versus schizophrenia, it's all part of a continuum.

But we will talk about these different conditions because it can influence our choice of medication and how we treat people.

Thanks for your email.

Let's go.

Next caller.

Hello, Jane.

Welcome to Matters of the Mind.

Jane, you had a question about Lexapro.

If you have weight gain from Lexapro, how long does it last?

Lexapro is a medication known as escitalopram came out in the early 2000s.

So it's been around for about 20 years now.

Some people will have this unusual weight gain from the selective serotonin reuptake inhibitors like Lexapro.

What Lexapro is basically doing, it's blocking the vacuuming of serotonin from the firing neurons.

So in your brain you've got 80 billion neurons.

And in your brain you have some of these neurons that will fire out serotonin when they fire out serotonin, just like a shotgun being fired out from a presynaptic neuron.

A shotgun fires out serotonin.

The serotonin can go to 14 different serotonin receptors, all different.

They all do different things.

Sometimes people will have more difficulty with serotonin related weight gain than others.

For you, I would wonder if there wouldn't be a better idea to go to a different direction.

Because if you're having weight gain on Lexapro, Lexapro is one of five different serotonin reuptake inhibitors.

There's also citalopram or Celexa.

That's simply the parent compound of Lexapro.

There is Paxil, which causes the most weight gain of the bunch.

Prozac probably causes the least weight gain of the branch, the result Zoloft and Luvox.

They all cause a different degree of weight gain.

If you're doing really well on Lexapro and it's fantastic for your mood or anxiety, by all means we'd probably not want to change it up too much.

But if you needed to go to a different serotonin reuptake inhibitor, we have some others from which we could choose.

How long does Lexapro weight gain last?

It can sometimes be ongoing.

If you just happen to be prone to having that particular difficulty.

Serotonin can affect, in some ways diabetes related receptors, and for some people, they will notice that they're having trouble with weight gain from that.

I'd want to know what other medications you might be taking.

Maybe it's not the Lexapro.

Maybe it's another medication you're taking.

I'd want to know what other influencing factors there might be or you're binge eating particularly.

Are you craving carbohydrates?

There's other ways that maybe can can be addressed with Lexapro related weight gain.

Thanks for your call.

Let's go to the next caller.

Hello, Paul.

Welcome to Matters of the Mind.

Paul.

You want to know, can depression and anxiety in teenage boys come across as anger and aggression?

Yeah certainly can.

Teenage boys are having that surge of testosterone and you indeed can have a lot of irritability and aggression when you're depressed and anxious as a teenage boy.

Now, how do you determine if a teenage boy is anxious and depressed, as opposed to just having a surging amount of testosterone?

I think you have to compare that particular teenage boys with the expected norm in that group.

If a boy is 14 versus 19 years of age, they should be able to control their impulses differently.

If the boy has a peer group that is naturally aggressive and violent, boys will often be very influenced by their peer group.

So if they're on friends who are irritable and aggressive, that will influence them.

But when we think about teenage boys and teenage girls for that matter, the front part of the brain is the last to develop.

It gradually grows over the course of 24 years of age.

I heard a politician just recently say that perhaps we shouldn't allow young adults to vote until they're 25 because their front part of the brain, which is the reasoning and the thinking part of the brain from part of the brain, is not fully developed until you're 25.

I don't know if we need to go that direction, but the front part of the brain, which is responsible for logical thought and subsequential behavior, it continues to gradually grow over the course of time.

And that's why when you're 14 years of age versus 24 years of age, you have a different outlook on life.

At least you should, because over the course of those ten years, this front part of your brain, which helps you with judgment, impulse control, thinking, logic, it's continued to grow over the course of time, so you should have a better outlook as time goes on.

But irritability, anxiety, anger yeah, boys especially can manifest that as symptoms of depression for some people.

We see it with young men and actually even middle aged men.

Men will tend to not get really teary and weepy when they get depressed.

Not uncommonly, men will have more difficulty with anger and irritability.

That's how they manifest depressive symptoms, not uncommonly so.

It might be a little bit of different symptom complex there with men versus women when they manifest depressive symptoms.

Thanks for your email.

Let's go to the next email question.

Our next email question reads Dear Dr.

Fawver, How do attention deficit hyperactivity disorder symptoms appear for women compared to men?

And do these change from childhood to adulthood?

Usually you'll hear about young girls and adolescent girls.

Young females who are adults are becoming earlier adult years.

They'll have more trouble with inattentive symptoms.

Boys and young men will often have trouble with inattentive symptoms and impulsivity.

Hyperactivity.

They're the ones that get in trouble in school.

That's why a lot of young girls who have all the symptoms of attention deficit disorder, they don't get in trouble in school, so they get kind of overlooked and nobody pays much attention.

They have to work three times harder than everybody else to be able to, to be able to comprehend information and to be able to concentrate on everything around them.

But they kind of get by and they might not notice that they have ADD symptoms or might not recognize it until they get to college.

Or maybe a job situation where somebody points out, hey, you're having a really hard time retaining information because you're not downloading it appropriately.

That's what happens with attention deficit disorder.

You basically don't download the information is coming in because your brain has the inability to shift that gear into the thinking or the remembering gear.

We have these different gears in our brain, just like the old car that were used to use the manual shift.

You've got the default mode network, and then you've got a gear that takes you from default mode network to the executive network.

That gear is called the salient networks.

In other words, when you have ADHD, you're prone to daydream.

You're prone to just think about the past.

You just your brain's not really kicking in.

Well, that's the default mode network.

We all have that.

Matter of fact, there's a phenomenon called highway hypnosis.

When you're on the interstate, you're driving down the interstate.

You're not thinking about anything in particular.

Next thing you know, about 20 miles go by and you realize that 20 miles have gone by.

It doesn't mean that you've had a seizure or a dissociative event.

It just means that you have just been thinking about different things.

That's your default mode network.

People with attention deficit disorder get stuck in that default mode network because they're shifter, which is the salient network.

The salient network doesn't work so well.

The shifter puts them into the executive network, where they can think and focus and concentrate even on things that are not new, exciting and challenging.

So people with ADHD can focus just fine on things that are exciting, challenging.

They're novel that they can't focus on things that aren't so interesting.

Now, all of us might have some trouble with things that aren't interesting, I get that, but we have a salient network.

If your brain is working normally, that'll shift you into that executive mode network, where it forces you to think and concentrate on something and pay attention to something that might not be that interesting.

So with inattentive symptoms, they will often kind of be discarded.

They'll be overlooked with young women.

Now the boys will get in trouble.

The boys will get in trouble to the point where they do things that might offend others.

They're impulsive.

They will do things and say things that get their teachers attention.

So ADHD, where they have the hyperactivity aspect of it, much more common with boys.

And it's thought that in the prison systems, in the prison systems across the United States, half of the prisoners have what could be diagnosed with ADHD.

Now there's different severities with ADHD.

That does not mean that if you have a mild or moderate ADHD, you're going to go to prison someday.

It doesn't mean that at all.

As matter of fact, people with ADHD often have higher IQs compared to people without ADHD.

It's just that you need to put that that high intellect to productive use.

And people who go into prisons often are very impulsive.

They do things without thinking, and one thing leads to another and they get in trouble with criminal activity.

So untreated ADHD can be very problematic and cause criminal activity for some people.

But there's different degrees of ADHD, just like there's different degrees of vision.

Vision disturbances.

Some people will have visual impairment where the first thing they need to do when they get out of bed every day is put their lens replacements in, they put their eyeglasses on, they can't see anything unless they have their corrective lenses available.

Other people don't need their corrective lenses unless they're or maybe doing some computer work or reading some fine print.

So just like visual impairment, there's different degrees of impairment with ADHD.

The people that have who have severe ADHD, they'll often come across as being bipolar disorder.

People are getting more educated on bipolar disorder.

Many people with severe ADHD will be misdiagnosed with bipolar disorder is a very important differentiation because we treat the conditions entirely differently.

You treat bipolar disorder one way, you treat ADHD another way, and some people will have both.

And if they have both, you treat the bipolar disorder, the mood disorder first, then you treat the ADHD symptoms.

So there's a sequence of treatment options we'll provide for people with ADHD and bipolar disorder.

But the difference between men and women.

Women will have more predominantly inattentive symptoms, where men will have inattentive symptoms and hyperactive and impulsive symptoms, especially when they're younger.

Over the course of time, the impulsive symptoms and the hyperactive symptoms often will settle down to some degree, not all the way, but the inattentive symptoms can persist.

A study I saw not too long ago said that 95% of people who had ADD symptoms or ADHD symptoms as children or adolescents still have them in their 20s and 30s, so they'll have symptoms.

But, you know, you're not in school anymore if you're in school and you have to sit in a classroom hour after hour after hour, that's horrific for someone with ADHD.

People with ADHD typically do better when they're individually tutored.

So if you can go to college or for that matter, you can go into a job situation that's interesting and exciting for you, and you don't have to sit in the same place hour after hour after hour.

Many times you can overcome the problematic symptoms that were there previously with ADHD.

Thanks for your call.

Let's go to our next caller.

Hello, Tammy.

Welcome to Matters of Mind.

Tammy, you had mentioned it's been a year since your boyfriend passed away and you can't seem to move on.

Is something wrong?

It depends.

Tammy, I think in your case, grieving is certainly normal for a prolonged period.

Depending on how well you knew your boyfriend, how engaged you were with him.

Maybe you were planning to be married someday, but the important thing for you is to continue to socialize and continue to talk to your primary care clinician who can, if you're not already doing so, refer you for counseling, because counseling can be very important for you.

What would a counselor do for you?

If you're mourning the loss of your boyfriend, the counselor can help you with social activities and looking toward the future as opposed to being preoccupied with the past.

Now, if you have a loved one who dies, my goodness, you're going to mourn that loved one at various degrees for a long time, and there's no set time on it.

It used to be a rule of thumb that maybe six months, you should be over grieving.

Well, it depends if it's a child or if it's a spouse.

You're going to be grieving for a longer period of time than that.

So I think it's all based on the context.

But you can always talk to a counselor about different ways to help you with the grieving.

And main thing you should be doing is continuing continuing to socialize the best you can.

Thanks for your email.

I wish you well.

Let's go to our next email question.

Our next email question reads Dear Dr.

Fawver, why do some mental health clinicians refer to the people they treat as clients?

What is the difference between clients and patients?

Well, this is a concept that's been debated for the past 50 years.

Back in the 1970s 1980s, there was a movement mainly among social workers and therapists to say, look, we're stigmatizing people with mental illness.

We're calling them psychiatric patients, and we're stigmatizing them, and thereby they don't want to be able to pursue treatments.

So we need to call them clients.

Clients sounds softer and more user friendly, but clients are what will be used if you're if you're seeking services with a financial planner, with an attorney, you're a client.

If you're seeking advice.

A patient, on the other hand, is somebody who is not only seeking advice, they're seeking treatment and they're suffering.

And that's very important, important to know.

Now, if you're seeing a tax advisor or an attorney, you might be suffering in various ways, but you're basically seeking advice.

The whole role of a clinician is to relieve the suffering.

Now, are there situations where a mental health clinician should be using the term clients?

Absolutely.

A lot of mental health clinicians do a great job with coaching people in life circumstances.

So premarital counseling, for instance, helping somebody transition from one job to another, they're not necessarily suffering to the point where they're impaired in their functioning, but they just need advice.

So if you're simply needing advice and needing kind of a life coach, by all means you're a client in that case.

But many of the people who see me, for instance, as a psychiatrist, they're crying.

They're they're having they're just not able to leave the house.

They're having trouble really getting along with sleep.

They're having trouble with focus and concentration.

They're on the verge of losing their jobs.

They are suffering.

So from my perspective, if somebody is suffering in their day to day activities, they're a patient.

In a similar manner, if you go see a cardiologist, if you go see a gastrointestinal for your gut, I mean, other clinicians will call their patients they see - their people they see patients because they are indeed suffering.

I don't think it destigmatize our field by referring to all of the people we see as clients.

Matter of fact, I think it minimizes their suffering.

So inadvertently, when the psychiatric or mental health care field try to destigmatize people seeking mental health treatment 50 years ago by calling these people clients, I think inadvertently they minimize their suffering because you're a patient, let's get you treated and let's get you feeling better.

And the whole idea with the patient is to have good, good overall outcomes and be able to have measurable outcomes that can determine that you're feeling better overall, the same as you would have in other areas of medicine.

Thanks for your email.

Let's go to our next caller.

Hello, Aaron, welcome to Matters of the Mind.

Aaron, you want to know how do you get your spark back for life after having depression?

The first thing you always need to do,Aaron, when you're recovering from depression and the symptomatic relief of depression is lifting and you're feeling better overall, the first thing you need to do is go back and figure out what did I previously enjoy doing?

One of the things that you did before you acquired depressive symptoms that you're not doing now.

So some people will say it's socializing, playing the music.

Some people will say it's going to church doing Bible studies.

They'll say it's quilting.

They'll give me all these different things they used to do, and they gave those pleasurable activities up when they got depressed.

And that's the worst thing you can do, because when you're no longer participating in pleasurable activities, that can be very detrimental and can predict you to be more likely to get stuck in depression.

So for many people who I see, okay, symptomatically, they're getting better.

They are more motivated, they have more energy, they have better concentration.

They have better self-esteem.

They're sleeping well.

Great.

Okay.

Now what's the next step?

And as clinicians, it's very importantly important that we look at pursuing the next step for people and allowing them to think about the things they used to do to find pleasure in things.

Now, my they might say, well, gee, I've been stuck in depression for three years, five years, ten years.

And they might be kind of stuck in that mindset where they haven't been doing a whole lot.

Get outside your comfort zone a little bit there, and start doing some things that you haven't been doing for a while, because the whole idea of treating somebody from a symptomatic standpoint of depression is to be able to take that next level.

No.

Now, I'll give you an example here in another area of medicine, if you get a knee replacement.

All right.

I've had a knee replacement.

Knee replacements are phenomenal.

If you get a knee replacement, it changes your life in many ways because you can walk again.

Well, with the knee replacement, you need to do your physical therapy and you need to do your stretches.

You need to do your bicycling.

You need to do your physical therapy.

And after the physical therapy, then you need to start using the knee again and you might say, well, wait a minute, my knees always hurt.

I haven't been able to walk.

I haven't been able to bicycle.

I haven't been able to do it to use the elliptical.

I haven't been able to do these different things.

Well, you got to start doing those because your knee is no longer hurting, presumably.

And that's where we really emphasize people to get back and doing things they used to do.

The same goes for depression.

If you've been depressed for a long time, it's very important that you get back in the game, start doing things that you maybe haven't done for a while, but you need to take it up to the next step.

Thanks for your email.

Unfortunately, I'm out of time for this evening.

If you have any questions that I can answer on the air, you may write me via the internet at MattersoftheMind - all one word - @wfwa.org.

I'm psychiatrist Jay Fawver and you've been watching Matters of Mind on PBS.

God willing and PBS willing.

I'll be back in next week.

Thanks for watching.

Good night.