Good evening.

I'm psychiatrist Jay Fawver, 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 that I can answer on the air concerning mental health issues, you may write me a via the internet at MattersOfTheMind - all one word - @wfwa.org.

That's MattersOfTheMind@wfwa.org.

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

So let's start with an email I recently received.

It reads Dear Dr.

Fawver, are there any non stimulating ADHD medications that are actually effective?

I currently take effect and Wellbutrin but could use something for ADHD.

Effexor and Wellbutrin are antidepressant medications.

It can help with some anxiety.

Wellbutrin has about half the potency of a stimulant.

So you're getting kind of indirectly a little bit of ADHD efficacy, possibly from from the Wellbutrin, also known as Buproprion all by itself.

So what are the non medications officially used for ADHD.

Well one has been around for a long time.

It's called atomoxetine, also known as Strattera.

Strattera is very specific and selective for enhancing norepinephrine.

So it'll give you about 90% potency for enhancing norepinephrine.

So increasing norepinephrine in the frontal lobe can help you pay attention to some degree.

Second medication is called Qelbree.

Qelbree is Viloxazine.

It's a medication that has been out for a few years now.

Qelbree has about half the potency on norepinephrine, as does Strattera.

But it also will also affect a couple serotonin receptors very directly.

And in doing so they increase serotonin transmission in the frontal lobe.

So Qelbree will enhance norepinephrine and serotonin.

It's thought that if increased serotonin for somebody with ADHD they can have less anxiety.

Many people with ADHD are always wondering where they put something.

They procrastinate.

They get behind on things they worry about different things.

And anxiety goes along with ADHD, not uncommonly so.

Those people could do quite nicely with a newer medication that just got FDA approved in July is called Simtriyo.

Simtriyo, S-I-M-T-R-Y-O, Simtriyo is a medication that has a chemical name that is very complicated to to to to pronounce.

But it's it's.

centanafadine.

Centanafadine.

So centanafadine is a medication that just got FDA approval.

And it's a very unique medication because it's increasing the transmission of norepinephrine, dopamine and serotonin, three different neurotransmitters.

And we've never had a medication that enhances all three neurotransmitters, presumably in the right balance for ADHD.

So number one increases in norepinephrine, secondarily increases dopamine and increases serotonin a little bit less.

So you might think, well, gee, the hows that's different from Effexor and Wellbutrin.

It's a bit different in terms of how much it will increase those ratios of norepinephrine, dopamine and serotonin.

But it's thought to be effective for ADHD based on how it works.

So some trio is a lot easier to pronounce.

Strattera is the trade name for that other medication, and Qelbree the second medication I mentioned.

Those are the three main medications used as non stimulant medications for ADHD for focus and concentration.

Sometimes we use medications like Intuniv, also known as guanfacine.

Clonidine can sometimes be used.

Those are more for distractibility and irritability and impulsivity.

But for focus in concentration.

Sometimes we'll use these non stimulating ADHD medications.

Now you have to remember you're on Effexor and Wellbutrin.

So there's a likelihood you may have to go off of one or both of those if you use these other medications because you don't want to overdo it with norepinephrine, serotonin or dopamine with these combination of medications.

Thanks for your email.

Let's go to our first caller.

Hello, Tim.

Welcome to Matters of the Mind.

Tim, you want to know why is Paxil hardly used anymore?

Well, Paxil is a medication that came out in 1994, I believe, and it's has a generic name called paroxetine.

Paroxetine.

And Paxil is a medication that very potently will increase the transmission of serotonin.

And in doing so, it also has some some secondary effects.

And the secondary effects of Paxil can be sedation and weight gain.

It's an interesting medication in the sense that it can increase the appetite and increase weight, unlike some of the other serotonin medications like Prozac and Zoloft and Luvox and Lexapro, Celexa.

These are all medications that will enhance serotonin.

Paxil will, too, but it does so in such a way that it can give somebody an increased appetite and an interesting phenomenon about Paxil.

It will inhibit its own metabolism, which means if you stop Paxil abruptly, it will decrease in its blood level really fast.

And in doing so, you can have some discontinuation symptoms, such as zings and zaps in the scalp, hands and feet.

You can have dizziness, lightheadedness, so some people can have some pretty nasty withdrawal from a medication like Paxil.

But Paxil historically over the years has been used for depression, post-traumatic stress disorder, panic disorder, obsessive compulsive disorder, social anxiety.

It's been used for menopausal symptoms at low doses.

So it's a medication that's been around for a long time, but it just has a lot of different side effects that sometimes are intolerable for people.

And now we have about three dozen other options for depression and anxiety we might use.

Thanks for your call.

Let's go.

Next caller.

Hello, Kate.

Welcome to Matters of the Mind.

Kate.

You want to know why do you keep forgetting where you put your car keys?

Is that a sign of dementia?

Not necessarily.

Kate.

Forgetting where your car keys might be placed as something that is a phenomenon that lies in this particular networking of your brain.

Now, there's like three, three networks of the brain that we use.

There's the default network, there's the salient network, and there's the executive mode network, the default network.

To use an old automobile analogy here, the default network is like sitting in first or second gear, barely idling, so your brain will kind of idle.

You're kind of thinking about this or that.

You're daydreaming.

You're not thinking about anything in particular.

You might be singing a song in your head.

You're not putting a lot of thought in what you're doing.

When you come into the house and put your car keys down, your thoughts aren't really focusing on, I'm putting the car keys right here, and I'm going to remember that you're just kind of naturally putting them here or there.

That's the default mode network.

Then you have what's called the salient network.

The salient network is like the clutch.

Now I'm really going back here, but in the older cars to go from first, second, third, fourth and fifth gear, you'd actually use a clutch in between.

The clutch will shift you from the default mode network, which is kind of the daydreaming non really thinking about anything mode to the concentrating focusing mode where you're going to try to remember things.

The salient network is the clutch that takes you into the third or fourth gear, where you're able to focus and concentrate on what you're actually doing, and you're trying to remember what you're doing.

That's the executive mode network.

So you've got these different networks going on in the brain, and depending on what network you're in, when you're putting those car keys down, you might forget where you put them.

Now, what I strongly suggest with car keys or now we have key fobs, put them in the same place every time.

That's the best way to remember where you put your car of keys.

Put them in the same place every time.

Even when your brain's in the default network, you're not even going to be thinking about where you're putting your key fob or your keys.

Put them in the same place every time.

That's the best way to get past that.

Thanks for your call.

Let's go to our next email question.

Our next email question reads, Dear Dr.

Fawver, when I read the patient information material on gabapentin, it says that I shouldn't take it with magnesium.

I take Tums every night.

So will that interact with gabapentin?

Well, first off, thank you so much for reading the patient information sheet that comes with the medications.

I'm always telling clinicians whether they be physicians, medical students, nurse practitioners.

I'm always telling clinicians who I train, that you need to remember that patients will read that patient information material, and you need to understand the context of what's in that patient information material.

Gabapentin will have an interaction with antacids.

You mentioned taking Tums.

Tums is actually calcium carbonate, but that is an antacid.

Calcium and magnesium will interact with gabapentin in such a way that they will latch on to gabapentin and decreases its absorption in the gut.

Now here's what would happen.

You're going to decrease the absorption of gabapentin by about 20%.

So if you have a 200mg dosage of gabapentin, you're going to get about 160mg of gabapentin, a little bit less gabapentin in your bloodstream because you took it with a magnesium and acid and or a calcium antacid such as Tums.

So if I'm a pharmacist and I was a pharmacist before I went to medical school as a pharmacist, I would certainly say, yep, you want to spread the dosing of your antacid with gabapentin apart because without understanding the context of the treatment as a pharmacist, I would say make sure not to take those two together.

As a clinician, I'm going to want to make sure you take the medication.

So if you are used to take in magnesium, for instance, at that time, because it helps with sleeps, it helps with muscle cramping.

It can help a lot of different things.

And you want to take the gabapentin with it.

Just be aware you're getting a little bit less absorption of the gabapentin.

It's not going to be perhaps clinically relevant or really pertinent to your treatment.

Just be aware that you're going to get a little bit less absorption of the gabapentin at nighttime.

So if you're used to taking a 200mg dosage, for instance, you're going to get about 150mg of gabapentin actually in your body.

Is that relevant?

Is that a big deal?

Probably not.

But for some people it might be.

What I would certainly stress as a clinician is that you take the gabapentin with the antacid kind of do it every night, do it on a consistent basis, because some nights you want to you don't want to have the lack of the antacid in your system.

And other nights have the antacid in your system.

I want to be consistent.

So night by night you're getting the same amount.

So if you're going to get in the routine where you take the magnesium or the calcium antacid with gabapentin, just do so every night.

Also obviously inform your clinician about that because perhaps you might need a little bit higher doses of gabapentin simply to override that little decrease in absorption you might get with the antacid itself.

So number one, yes, you're going to get about 20% less absorption if you take gabapentin with an acid that contains calcium or magnesium.

And number two, if you do so, just be aware that you tell your clinician that you're taking them in together.

It's not an absolute prohibition to take that combination.

It's just that you're going to get a little bit less absorption if you take it with the take the antacid with the gabapentin.

Thanks for your call.

Let's go to our next caller.

Hello, Tyler.

Welcome to Matters of the Mind.

Tyler, you mentioned you're having extreme fatigue a month after stopping duloxetine.

Is that related?

It's been a month since you took duloxetine, that's also known as Cymbalta.

Tyler, usually if you stop or you're tapering off the Cymbalta duloxetine, you're going to notice some withdrawal symptoms or discontinuation symptoms within a week or two.

A month later, having extreme fatigue, I'd wonder if that wasn't the duloxetine which enhances norepinephrine, which is energizing, and serotonin, which is calming.

I'd wonder if the deluxe wasn't helping you some with your energy.

So if it's been a month, I doubt the duloxetine is really having a big impact on you now because it's well out of your system and you're probably not having any discontinuation symptoms from it.

But a month down the line, yeah, the fatigue is probably from the benefits that duloxretine was helping you with that.

So it might be another issue you're having there.

Thanks for your call Tyler.

Let's go to our next text.

Hello, Kim from Portland.

You're texting us about venlafaxine.

You've been on venlafaxine for a really long time, and you'd like to know how to get off of it.

How hard is it to stop venlafaxine?

Venlafaxine is also known as Effexor.

It came out in 1995, Kim.

And it was a medication that increases norepinephrine and serotonin.

So we like a lot of features of venlafaxine, it came out in the immediate release tablet in 1995.

So it says that people would have to take it three times a day to be in a steady, in a steady state.

However, we quickly found out back in the late 1990s that when people missed a dosage of venlafaxine, they felt like they were having a stroke.

So they'd have these zings and zaps, dizzy spells, lightheadedness.

They'd feel unsteady.

They felt miserable if they missed the dosage.

So then in the late 1990s, they came out with an extended release formulation of venlafaxine.

Undoubtedly, that's what you're taking is called venlafaxine XR.

That's once a day dosing.

But even with the XR, you have to be careful on how you taper off of it.

As a general rule of thumb, I will have people taper off of venlafaxine for six days for every 37.5mg amount they're taken.

So if you're taking 75mg a day, I'm going to have you take 30.

I'm going to have you.

If you're taking 75mg a day, I'm going to have you take 37.5mg a day for six days, then stop it.

If you're taking 150mg a day, very common dosage.

I'm going to have you take 112.5mg a day for six days, 75mg a day for six days, 37.5mg a day for six days.

And then you go off of that.

So if you're taking 150mg a day, I'm going to have you go off of it over the course of 18 days and the same for higher doses.

So basically it depends on how high of a dosage you're taking.

And I'm going to have that strategy in mind for you, where you're going down by 37.5mg every six days.

And if that's too much for you and you're still having some zings and zaps and some lightheadedness, by all means we're going to slow that whole process down and go off of it more slowly.

But I wouldn't suggest that you go from 150mg a day to nothing, or even 75mg a day to nothing, because you're going to have some uncomfortable days for 6 or 7 days.

So we often recommend a slow tapering.

And if you're on 150mg a day, it could take you up to to two and a half weeks or so to be able to get off of that, but that's okay.

You can get off of it.

Some people will give up on trying to taper the venlafaxine because getting some symptoms from them.

There was an old trick back in the old days of adding on fluoxetine, also known as Prozac, which lasts a long time.

Doesn't work that well in my experience.

Usually just doing a nice slow taper of venlafaxine is usually the best way to go to decrease those discontinuation symptoms.

Thanks for your text.

Let's go to our next caller.

Hello, Louie, welcome to Matters of the Mind.

Louie, you want to know about the difference between sertraline and buspirone?

Is one better for anxiety?

Sertraline is known as Zoloft.

Came out in 1992 and Buspirone came out in 1984 1985.

It's been around for a long time.

Buspirone will very specifically and selectively affect one of the 14 different serotonin receptors.

So if you think about serotonin, have a bunch of targets out there and there's 14 different targets, buspirone is going to one of them.

It's called serotonin 1A receptor.

Sertraline Zoloft on the other hand is hitting hitting all 14 receptors.

So they both help with anxiety.

That's the long story short.

Buspirone is very selective in what it's doing.

Very well tolerated for a lot of people.

It can give you some double vision and some lightheadedness when you first start taking it, especially at too high of a dosage, most people will start taking you buspirone five milligrams twice a day, and we go up to 30mg twice a day.

Many clinicians will prescribe you buspirone three times a day because number one, that's how the textbook say to do it.

But secondly, a lot of people won't remember it three times a day.

That's why I don't usually prescribe it that way.

So I typically will prescribe it twice a day.

And it tends to work twice a day dosing for a lot of people.

But you buspirone is good for worry and ruminating and dwelling on things.

The what if, what if, what if thinking in the in the mind, Louie.

So if you're dwelling on things, you're worrying about things, you're thinking about possible things that can happen in the future and you're worrying and worrying.

Buspirone is good for that.

We use it for a lot of college students.

We want the college students to be sharp.

We want them to be able to concentrate.

We don't want them to be sedated.

We want them to be able to download information in their brains.

But we don't want them to feel overwhelmed with worry and anxiety.

And that's why we use buspirone for them.

So buspirone is good for worry.

Zoloft or sertraline as I mentioned, it affects all the different serotonin receptors.

It can be good for generalized anxiety, also known as worry.

It can be good for panic attacks, social anxiety, obsessive compulsive disorder.

It can be good for lots of different types of anxiety.

Post-traumatic stress disorder.

So sertraline has a broader spectrum of treatment that can be available to it.

Where you buspirone or Buspar is more specific for the worry.

If you give somebody buspirone or Buspar for panic attacks, post-traumatic stress disorder, social anxiety, it might not work out well, whereas Zoloft or sertraline might work better.

So they're entirely different medications, but they do affect serotonin in different ways.

Louie, thanks for your call.

Let's go to our next email question.

Our next email question reads, Dear Dr.

Fawver, why do some people struggle with traumatic experiences and others don't?

What's the best therapy for people with post-traumatic stress disorder?

It really is based on some people will struggle with traumatic experience.

Some people don't.

Based on number one, your genetics, that's about 30% of how your hard wired.

And that will affect the likelihood of your getting PTSD.

If you've experienced past traumatic events and you've dealt with them well and you've coped with them well, you've become hopefully not only resilient where you put up with them well, but you have an anti fragility.

Anti fragility is this opposite of fragility.

People who have a lot of fragility are people who fall apart with the least little circumstance that's challenging or oppositional to what they're accustomed to experiencing.

So fragility is something where people have very little stress tolerance, and they have a lot of difficulty putting up with pretty much anything.

Anti fragility is where not only do you put up with something well, but you learn from that experience and you get stronger with each challenging experience.

So we're always looking for ways to get people to get stronger.

From personal experience we call it neuroplasticity.

Little brain neurons, they actually get more fluffy if you're learning from challenges and from traumatic experiences.

So some people will have fragility.

Some people are just able to put up with things.

They could put up a thing, but they don't learn a lot from them.

That's called resilience.

And then you have the anti fragility where people can actually learn from past experiences.

How do you get over post-traumatic stress disorder?

Avoidance is not the way to do it.

So avoiding circumstances, avoiding triggers for trauma won't necessarily be the best way to overcome them.

I think the best way to overcome past traumatic experiences is modeled for us in the Book of Numbers.

I think it's chapter 21.

The Book of Numbers is in the Torah.

It's one of the first five books of the Old Testament, and in the Book of numbers, the Israelites who are accompanying Moses out of Egypt, and they're on their heading toward Canaan.

They start grumbling and next thing you know, a bunch of vipers start biting them.

And the Israelites are getting bitten by vipers.

Some of them are dying, and they ask Moses to give them some direction on what to do about all these vipers.

And well, he asked God, and God says to to build a bronze serpent and put it on a big pole.

And they put this serpent on the pole, and they're instructed.

The Israelites are instructed to look to the bronze serpent on the pole.

And that's that was healing them, and that was healing them from the viper strikes.

So what it's doing is telling people to look toward the source of your trauma and deal with it right up front.

We call that nowadays in psychiatry exposure therapy.

So with exposure therapy you're being exposed either imagining it in your head or maybe visualizing it through some computer technology.

You're actually exposing yourself cognitively to the source of your trauma itself.

So you're trying to deal with it in a non emotional manner.

So if you're dealing with it in a non emotional manner, you can get over the trauma in much better way.

So that's exposure therapy with post-traumatic stress disorder.

And there's a particular treatment called rapid resolution therapy, RRT, where people talk about their past trauma in a non emotional way.

It's an interesting technique, but the whole idea is to basically rationalize and cognitively process your trauma and your front part of your brain as a as opposed to allowing your amygdala in your limbic system in the middle part of your brain.

That's your emotional center.

You don't want that to hijack your thinking part of your brain.

So with post-traumatic stress disorder, you've experienced the trauma.

And that emotional trauma has caused you to hijack your thinking part of your brain.

So what you're trying to do is get the thinking part of your brain to work more for you by actually confronting the trauma head on in a non emotional matter, whether it be Moses building the bronze serpent, putting on a pole so people can look that direction and and overcome the viper bites, or whether it be thinking about a past trauma you've experienced in a not emotional manner, they could both be very effective for post-traumatic stress disorder.

Thanks for your call.

Let's go to our next text.

Hello, Pat from Fort Wayne.

You've been you had a question about the gabapentin and you mentioned on the gabapentin question was that just anti anxiety medications or also magnesium vitamins, too.

Yeah that's includes magnesium or calcium supplements.

And many people will use them interchangeably.

They'll use magnesium as a supplement that can by itself help with sleep and sometimes muscle cramping.

Or they'll use the magnesium that can help with stomach upset.

Calcium is the same.

Calcium all forms of forms of calcium, all forms of magnesium.

They can grab on to the magnesium, they can grab onto the gabapentin and just decrease the absorption of about 20% of it.

Not a big deal usually, Pat, but talk it over with your clinician.

Is that big of a difference for you to take, for instance, 160mg of gabapentin, which is what you'd get if you took a 200mg dose of gabapentin.

That's what you'd get if you took it with a magnesium or a calcium supplement.

Is that that big of a deal for you?

Now?

It could be used to be back in the 1980s when gabapentin, also known as Neurontin, by the way, when it first came out, it was used for seizures.

When you use any medications for seizures, you want a very steady blood level and you want a blood level that's going to be very steady.

So maybe you don't want to go up and down on those blood levels.

And by golly, you want to make sure that you don't take any calcium or magnesium with the gabapentin to maintain that steady blood level.

But I would just say from a practical standpoint, from an adherent standpoint, I want to make the medication easier for you to take.

I want to be practical about it.

If I'm telling you that you've got to take the calcium or magnesium a couple hours before or after the gabapentin, you might not take the gabapentin for that matter.

So I want to make it simple.

But what I'd really emphasize as a clinician, if you're going to take gabapentin with a magnesium or calcium supplement, do so in a very consistent manner.

Night by night.

Let's go to our next text from Pat.

Pat, you also wonder about quetiapine fumarate that's also known as Seroquel.

Can it cause a fast heart rate, blurred vision, and itchy skin?

Two of the three fast heart rate, blurred vision, itchy skin.

And the first thing I'd wonder would be are you allergic to it?

So when I hear about any patient having itchy skin from any medication, I wonder, is that kind of an allergy that can be transient?

Sometimes it will go away, but I'd wonder if you're having itchy skin from any medication.

Are you allergic to it?

Quetiapine specifically is a very strong antihistamine, so if anything, it's blocking histamine.

I wouldn't expect Quetiapine to make your skin itchy.

If anything, it's going to decrease itchiness.

We actually use quetiapine for a lot of people who have allergic conditions where their skin will be affected can cause blurred vision.

Can it cause dizziness?

Can it cause dry mouth?

Yeah, it can do any of those type of things because it has side effects that are so-called anticholinergic in nature and they can block acetylcholine, and in doing so cause some of the other symptoms that you described.

But itchy skin not as likely.

Thanks for your text there, Pat.

Let's go to our next caller.

Hello, Molly.

Welcome to Matters of the Mind.

Molly, you want to know as kids are in school, what's the best way for them to be able to learn?

Well, the first thing I would recommend, Molly, would be what I've been telling medical students for the past 40 years is to try to make your your learning interesting and try to understand what you're learning is practical in your later life.

So when I'm teaching medical students, for instance, and I'm talking to them about these different disease concepts, these treatments, I'm trying to have them think about patient scenarios in terms of how it might apply to them.

And even with school kids, teachers need to tell stories.

They need to make it interesting.

And teachers need to be enthusiastic and motivated because you don't want to have a boring teacher boring the kids.

So the teacher needs to be enthusiastic and motivated.

Secondly, you know when your kid comes home at night, don't simply ask, what did you learn today?

Ask what questions did you ask today?

I strongly encourage children and students to tactfully ask questions, ask questions, ask questions, and try to learn by asking questions.

The Socrates always - and Jesus taught this way as well - where they would ask questions as teachers to the kids.

But the kids need to be asking questions back.

So as you're learning material, you want to be learning by asking questions back overall and make sure they get enough sleep at 30 minute nap at the end of the day can really be helpful.

Unfortunately, Im out of time for this evening.

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

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

I'll be back again next week.

Thanks for watching.

Good night.