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

Welcome to Matters of the Mind now and his twenty fifth 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 thirty nine in the Fort Wayne area by dialing (969) 27 two zero or if you're calling coast to coast you may dial toll free at 866- (969) 27 two zero now on a fairly regular basis we are broadcasting live every Monday night from our spectacular PBS Fort Wayne studios which lie in the shadows of the Purdue Fort Wayne campus.

>> If you'd like to contact me with an email question that I can answer on the air, you may write me via the Internet at matters of the mind all one word at WFA ECG that's matters of the mind at WFYI Doug and I'll start tonight's program with a question I recently received.

It reads Dear Doctor Father my doctor has been talking to me about ketamine also known as bravado.

Why does it have to be taken in the office instead of just filling a prescription and taken at home?

Escott Amin is also as I mentioned known as bravado.

It's a nasal spray and as a nasal spray it's not like Afren or it's just going to give you a decongestant effect in your nasal passages.

Eschaton means getting preference preferentially absorbed in your nasal passages and it's getting to the brain thereby not needing to go through the liver.

If it goes to the liver first it all gets broken down so it's not given as an oral medication that way it's given as a nasal spray and what you notice with this ketamine is you can have within 20 to 40 minutes after the administration of it dissociation association is kind of like an out of body experience where you can have a floating sensation.

You can see things around, you move and for some people it's somewhat anxiety provoking for a first few minutes.

But then after they notice it's settling down, they feel calmer and with their second and third treatments they often have less anxiety about the dissociation.

But that's one reason a second reason people need to be monitored while they're having a set of treatments will be their blood pressure can spike also at about the 40 minute mark to mean when given in the intranasal form will peak in its blood levels at about forty minutes after you use it.

So at forty minutes you have the most dissociation at forty minutes you have sedation and you have the higher blood pressure occurring that time at about one hour after the first spray you to notice that the dissociation, the sedation and the higher blood pressure tend to settle down and by two hours when somebody leaves the office they will often well feel as normal as they did if not better when they came in.

So they still are not expected to drive or operate machinery for the rest of the day and always have to remind people machinery includes chain saws so you cannot operate any machinery at all including chain saws for the rest of the day.

The next day you can operate machinery once again and what's the end of a day?

It's basically when the sun goes down and as some goes back up that's the time frame.

That's the end of the day.

When the sun goes down, the sun comes back up then you can drive and operate machinery again.

>> Why can't you just do that at home at the concern from the Food and Drug Administration is that if you use it on your own as a nasal spray and just kind of chill out for that period of time, you won't be monitored with blood pressure.

Dissociation might be problematic and you might just on your own go out and drive and the Food and Drug Administration wants you to be monitored during that time by a health care professional which can include a nurse or medical system.

>> Now you'll need to be in the office with a health care provider, a prescriber so you'll have a prescriber or a provider in the office.

>> You might not see that particular provider that day but the provider needs to be in the office.

You might see a provider by video and that's how our office will often see people with us getting the clinician the provider, the prescriber will see the patient by video and then the after assessing them for how the medication has been doing and determining if they're ready for the next treatment typically twice a week the first month once a week, the second month and then every other week or once a week thereafter and sometimes people stretch out the appointments even more so but the clinician who's prescribing the medication will determine at what dosage is going to be the best dosage for that person and how frequently they should be seen.

But as ketamine or ketamine those are in the same class.

Ketamine has been researched since nineteen in the nineteen sixties and it was food and it was Food and Drug Administration approved for anesthesia in nineteen seventy.

So ketamine is the formulation that's used IV sometimes it can be used intranasal but s ketamine s is in front of ketamine as ketamine is twice as potent as ketamine and that's why ketamine was used as the form of ketamine to be able to use intranasal formulation.

>> The problem with ketamine injections IV is they're not monitored at all.

>> It's not approved by the Food and Drug Administration which means you'll be paying several hundred dollars typically out of pocket for each individual treatment and if something does happen that's unfortunate the malpractise carrier might not cover that clinician very well.

So clinicians have some reluctance to use ketamine for the purpose of it's off label use for depression.

Now ketamine can be used extensively for a lot of other purposes such as anesthesia but for the purpose of treating depression there's a lot of variability on how ketamine is being used whereas ketamine is bravado has very strict guidelines based on the Food and Drug Administration's.

It's called a Risk Evaluation and Mitigation Strategy program where after every treatment with ketamine you have to submit to the FDA specific information on how the patient did.

You don't have that risk with ketamine.

So ketamine is much less regulated as ketamine is much more regulated overall.

So there are differences and what we have found over the past three and a half years now that ketamine has been available is that some patients who had had severe unremitting depression with various oral and a present medications, they just weren't getting better all of a sudden with ketamine they tended to have improvement sometimes within two or three treatments.

So with ketamine you can often have dramatic treatment responses within two or three treatments we try to have people hang in there for at least a couple of months of treatment.

But more often than not you see people have a scenic a significant response to treatment within one month so sometimes within two or three treatments very frequently within one month and occasionally people need that second month of treatment to really see that meaningful benefit now along with ketamine and for that matter if you're using ketamine off label for the treatment of depression ,you typically want to stay on some kind of antidepressant medication, some oral and depression medication with ketamine that's actually highly recommended and mandated that you stay on some kind of oral and appropriate medication as ketamine and for that matter ketamine are not expected by themselves to allow a person to recover or be cured from depression.

They work entirely differently than the oral antidepressants.

There's been about oh sixteen oral antidepressants become available since nineteen eighty seven so in the past thirty five years we've had about 16 different oral and depressants become available as ketamine basically will work in an entirely different way than the traditional oral antidepressants.

The traditional oral antidepressants mainly work on serotonin, norepinephrine and dopamine.

Those are the three chemicals that have been discussed extensively for the past three decades with ketamine ketamine.

>> We have a new medication called Valide.

These are medications that are primarily working on glutamate.

So we're not talking about norepinephrine serotonin and dopamine exclusively in treating depression now now we're talking about glutamate.

Glutamate is entirely different chemical.

It's an excitatory chemical in the brain that needs to be just the right amount.

You don't want to feel excitement.

You don't want too much excitement.

So it's not unlike the speed of a car if you're driving down the interstate and the speed limit is 70 miles an hour while you ought to be around 70 miles an hour if you're going 40 miles an hour on the interstate, you're not going fast enough.

You're going to get run over.

You're going to cause an accident if you're going one hundred mile an hour on the interstate you can be somewhat reckless and that's considered to be illegal and you can cause an accident if you're going too fast or going too fast or to going too slow on an interstate can cause an accident.

>> So what you're wanting to do with the use of any medication that's regulating glutamate, you want it to have it just in the right area, the right amount with the medications coming out such as ketamine, ketamine or Valide has Dr Mathoura fan in it.

They're all affecting glutamate but they're actually blocking excessive glutamate transmission.

But if you don't have enough glutamate transmission they're increasing it.

>> So it's giving that balance of giving you enough glutamate transmission that will be beneficial for you.

The advantage of the glutamate antidepressant medications will be that they work fast, they work on the ion channels.

They don't work on just protein receptors which is primarily how the traditional antidepressants have worked on serotonin, norepinephrine the dopamine.

They work on protein receptors and it takes six to eight weeks for those little protein receptors to get built to be able to normalize how the brain is functioning.

That's why takes them so long to to work with the glutamate medications ketamine as ketamine Valide these are medications that are working on the little ion channels ion channels wub will be effective within a matter of milliseconds once the drug reaches that mark.

So these medications are working very, very fast sometimes within a matter of one or two days, sometimes within a week or two with our patients on all Valide for instance right now we are seeing them up very, very meticulously within a couple of weeks of ality came out in early October .

So we're watching these patients very, very carefully and we're watching them within a couple of weeks because we expect to see some kind of difference what you're not going to be seeing with these glutamate medications as much as the older medications will be the mental darling where you have this brain fog, the older antidepressive medications, the ones that affect serotonin particularly can give you a sense of emotional blunting where you don't feel happy, you don't feel sad, you just kind of feel blocked.

The glutamate medication shouldn't do that and they also shouldn't cause sexual disturbances and they don't cause weight gain sounds pretty good will they?

Cause they can cause some dizziness with day to day use what like with all Valide with the dextromethorphan can cause some dizziness as the main side effect a little bit of nausea sometimes so we're going to be watching for how these medications work over the next few years but it's going to be a whole new world in the treatment of depression and anxiety over these next few years.

We have a lot of medicinal treatments coming available that just haven't been available over the past few years.

So we're going to get away from using the traditional medication.

Is that primarily an exclusively increased serotonin, norepinephrine and dopamine?

We'll probably going to be going a different direction over these next few years so it'll be exciting time in psychiatry.

>> Thanks for your email.

Let's go to our first caller.

>> Hello Frank.

Welcome to Matters of Mind.

Frank, you mentioned you have diabetes and will that affect the medication prescribed for anxiety depression?

Frank, that's an interesting question because it's thought that Type two diabetes and I'm going to start with that because it's the most common type of diabetes where you have adult onset diabetes let's say type two diabetes is where your insulin goes higher and higher and higher and then it just can't keep up with the demands and your blood sugar start to go higher and you have what's called insulin resistance, insulin and sensitivity.

And the bottom line is you have high insulin levels and your body's just not responding to it and then you get high blood sugars.

So we have to remember that a hundred years ago in Madison, Wisconsin, a psychiatrist by the name of Llorens wrote in the Archives of Neurology and Psychiatry that people with schizophrenia and what we now know is bipolar disorder had a higher than expected blood sugars in nineteen twenty two one hundred years ago.

So we need to remember that the condition of schizophrenia, bipolar disorder and now we know depression and various anxiety conditions those conditions can give you a higher likelihood of having Type two diabetes where you have higher insulin levels and more insulin resistance.

So we need to keep that in consideration and thereby thereby watch glucose levels very carefully for somebody.

>> And I'm certainly not opposed to checking in insulin level for somebody to see if it's going higher and higher and higher on occasion you check it about eight hours or more after somebody has last eaten but will medications that you're using affect your diabetes?

>> We have to be careful about that in terms of interpreting how the antipsychotic medications might affect diabetes, we have warnings concerning antipsychotic medications.

The main ones used for anxiety and depression are medications such as a Bill Abilify result will use sometimes Seroquel.

Well you'll hear about using that with depression anxiety there.

Add on medications to help antidepressants work for depression anxiety and you'll see the warning on their package insert saying they can sometimes worsen diabetes and make blood sugars go higher.

They might may or may not do that by themselves.

That's always a point of debate.

Again, we have to remember that the underlying condition of depression, anxiety, schizophrenia, bipolar disorder all can increase the likelihood of diabetes so well there will be a direct medication to medication interaction not necessarily if using metformin and some of the newer diabetes medication there's no evidence that they will directly interact with medication we're using now for depression and anxiety.

So that shouldn't be a concern.

There shouldn't be a medication, a medication interaction there that's called a pharmacokinetic interaction.

The pharmacodynamic interaction is where the medication is causing the diabetes or the diabetes is making the medication not work so so well anymore.

So those are the kind of things we're already considering but it's not a medication medication interaction as much as is its underlying disease state interaction with how much the disease state is contributing to the actual higher blood sugars themselves.

Depression anxiety can give you the higher blood sugars and that's important because you have to remember that if somebody has sky high blood glucose they're going to be able to think very clearly.

>> They're going to have trouble with fatigue, they're going to have trouble with poor vision.

They're going to have trouble with sleep.

They'll be awakening throughout the night.

Those are all symptoms of high blood sugars when your blood sugar gets over two hundred at nighttime, you're one to get up to go to the restroom all the time to urinate.

So we have to remember that high blood sugars themselves can cause a lot of the conditions that we know are symptoms of psychiatric disturbances like depression or anxiety.

So if somebody has diabetes we're checking their blood pressures, their hemoglobin A1 CS which looks at the average blood glucose over the past two or three months.

Basically we're looking at those A1 C's to really determine is it the blood glucose glucose its high that's causing the symptoms of fatigue and poor concentration that somebody might experience or is that the underlying depression or anxiety causing those kind of problems?

>> So that's why as a psychiatrist I'm a medical doctor first I'm always looking for diabetes.

I'm looking for other medical conditions like thyroid disturbances, ion disturbances, sleep apnea.

These are all medical conditions that go hand in hand with a lot of psychiatric symptoms.

We have to determine if somebody's having those kind of medical conditions first and foremost before we jump in there and determine or just conclude that somebody has symptoms of depression or anxiety that it's due to a brain abnormality itself.

Frank, thanks for your call.

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

Our next e-mail question reads Dear Dr. Fauver, what is transcranial magnetic stimulation therapy?

TMS therapy?

My doctor wants to try it.

It sounds like that involves some fancy technology.

>> I'm hoping it will help my depression basically TMS was studied and researched and approved over twenty years ago and it's where you are firing up certain parts of the brain with a transcranial which means going across the skull magnetic stimulation so used to be all TMS treatments were like thirty one minutes, five days a week Monday through Friday for six weeks and they were done primarily on the left front part of the brain.

>> Well now we have all this newer technology with functional MRI that can scan the brain very quickly and determine where best that TMS well should go should it go on the left side should go on the right side and they can actually place the TMS Cuil more appropriately and in doing so the TMS sessions are much shorter and what I believe is going to happen will will seize TMS to be a standard of care in hospital settings.

For instance somebody comes in the hospital and they're extremely depressed or suicidal .

I think TMS is going to be a standard of care in the hospital setting because in the hospitals you have the MRI machines, you'll hopefully have the TMS machines and I think the TMS will be done over the course of maybe five consecutive days with this very specific potent and focus treatment that we don't have across the board right now.

And you might have five consecutive days of TMS treatment and that'll make you feel a lot better.

>> I also think that ketamine will be used more extensively in the hospital treatment or in the hospital.

You can rest, you can have dissociation there.

I think that'll be a standard of care in the hospital.

>> Ketamine which I mentioned earlier is the precursor or the parent compound of ketamine.

I think ketamine is going to be more creatively used over the course of time again primarily in hospital settings where people are already being monitored anyway.

>> So ketamine I think was going to be used in different formulations not just through IV formulations but in different formulations in the future.

So I kind of see that coming as ketamine is a left sided piece of ketamine.

So the left side of piece is four times more potent than the right side of the piece of ketamine.

So that's why it's got to be and is used as an intranasal compound to effect glutamate, try to get people feeling better.

But TMS transcranial magnetic stimulation it's main side effect is a little bit of a headache sometimes but people with TMS can have their TMS first thing in the morning and go right to work.

They can drive.

They can operate machinery.

Not a problem with TMS.

It was originally thought my goodness twenty twenty five years ago when I was first getting research that it might cause seizures and that was a big apprehension a lot of people wasn't found to be the case.

So it doesn't seem to cause seizures.

It's something that gives the brain some stimulation and originally it was studying the left front part of the brain.

The left front part of the brain is a little bit underactive when people get depressed.

So when you get depressed you have trouble with having trouble with concentration processing information, decision making and then you get to the point where you can feel kind of tired and blah and you don't have a lot of energy, you don't have a lot of motivation to do things and that's coming from the middle part of the brain due to an inflammatory effect.

So we now understand depression as being a condition where the brain is not functioning.

The brain needs to function for you to be able to think and concentrate and think through your different challenges day by day.

But you also need energy and it's thought that you when you lack enjoyment things you lack motivation and you have low energy that's due to inflammation.

>> So when we talk about ketamine and we talk about our Valide with dextromethorphan, these are medications that don't just modulate glutamate like I mentioned they also have an anti inflammatory effect so they also have effects on the brain will decrease inflammation inflammation not only as seen with depression but it's also seen with bipolar disorder when people are manic.

So when people are manic there's this protein in their brain called s 100 that go sky high and when it's one hundred go sky high you get manic and it's an inflammatory state of brain.

That's why we use lithium not uncommonly as a means of decreasing the inflammation in the brain when people are manic we use lithium, Depakote, various other types of medication as a means of decreasing inflammation.

TMS I don't think we know enough about it to really determine if it's affecting inflammation or not but we do know it stimulates parts of the brain that seem to be underactive.

So with underactive areas of the brain you can stimulate as parts of the brain and try to get the brain back on track when people have depression and they have trouble with anxiety and they have trouble with motivation not uncommonly the nice thing about TMS outside of the headaches not a lot of problems with it.

I mean it's not going to cause weight gain sexual disturbances.

It's not going to cause some of the side effects of the older traditional antidepressants have been known to cause.

So that's where it can be really helpful for a lot of people there is a time commitment to it.

Sometimes insurances pay for it, sometimes they don't.

So there can be a cost commitment to it in terms of its effectiveness, its effectiveness is probably a bit less than the antidepressants.

Now that's in contrast to ketamine and ketamine that you'll hear about the effectiveness of those medications are much more robust than the antidepressants.

But with TMS the hope is as you can get more focused and you can find exactly what part of the brain needs to be stimulated though the efficacy the outcome can be much higher than what was originally seen with it.

>> Thank you for your question.

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

Our next e-mail question read your doctor Fauver.

>> How has psychiatric treatment changed since you came out of training?

I came out of training thirty five years ago so it's it's changed a lot.

>> When I was in medical school I had come to pharmacy school and I was a pharmacist.

This is back in the early 1980s and I decided in nineteen eighty three I was going to go into psychiatry and at the time I was question why are you going into psychiatry because of psychiatry.

They don't use that many medications.

I was intrigued by the neuroscience of the brain in nineteen eighty three and with a few medications that were used the psychotics that a handful of Anna presence lithium was available at that time I was intrigued on how well they worked by helping somebodies perception of the world around them because I'd see these people who were floridly psychotic they were out of touch with reality.

They'd be given low doses of those old or antipsychotic medication like Thorazine, Haldol, Prolix and and within a matter a few of a few days they were not as psychotic.

Now they might not have been able to think very clearly still but they didn't have these wild thoughts they had before and I was very intrigued by that and I was also intrigued because there were so little known about the brain chemistry at that time and I knew the over the next few decades it wasn't going to be boring and it wasn't in nineteen eighty seven when I came out of my residency one medication changed everything and that was Prozac Prozac was the first antidepressant of all the depressants that made it acceptable to take an antidepressant the Prozac there were the older antipsychotic medication Synacthen Ellisville tofor and people didn't want to take those medications that cause dry mouth cause weight gain.

They caused sexual disturbances.

They made people feel and act dull so people didn't want to take the older antidepressant medication.

>> So with Prozac it was the first medication it became acceptable to take because it's helped with mood.

But yet didn't cause all the side effects the older ones did.

Well what happened?

Prozac a lot of people took Prozac, many of them inappropriately.

If you had bipolar disorder you shouldn't take Prozac because you shouldn't take any antidepressants.

Some people got in trouble Prozac for that reason Prozac ended the 1990s had got a bad name not because of anything about the molecule itself.

It was just getting inappropriately prescribed.

So over the course of time what happened we had as I mentioned earlier, fifteen other oral antidepressants come out now we have ketamine, a nasal spray ketamine's, an I.V.

injection.

We have all these different treatments coming out and I think the technology is just going to explode over the next five or ten years in a way that we hadn't seen before.

So psychiatry is a medical specialty.

I think it's going to be more outcomes based where we're going to be able to measure outcomes in the similar way as we do with other medical specialties.

So I think psychiatry will be known more as a medical specialty as opposed to oh, a kind of treatment approach where you're basically using your intuition as a clinician.

>> I think we'll be able to measure our outcomes for people.

Thanks for email, Dean.

>> We have about a minute and a half welcome to Matters of Mind.

I was wondering about anxiety cause itching sensation like all over your body kind of like neuropathy.

And I was also wondering what your opinion was on the Daylight Savings Time if that's really going to have an effect on people.

>> They get that change back then I hope they change back to the Daylight Savings Time.

There's a few people out there I hear about it occasionally but for a few days after Daylight Savings Time they're having a hard time waking up or they're having a hard time going to bed for an hour or so.

Usually people adapt pretty well because if you change your circadian rhythms for a few days which you have to do after Daylight Savings Time, you tend to adapt and people can adapt.

So yeah, I don't think that's going to be a major issue for people but that's what the politicians are trying to decide right now.

Can you have blurred vision with anxiety?

You bet because when you get anxious your pupils dilate when your people's daily that can give you blurred vision once in a while when people get really anxious histamine gets released so in histamine gets released in the skin it wakes you up but it also gives you an itching sensation.

>> So some people get kind of itchy when they get anxious and there's a condition called neurotic dermatitis where people it's so much when they get anxious we have to give them a bit of an antihistamine to settle that down.

Dean, thanks for your call.

Unfortunately I'm out of time for this evening.

Any questions concerning mental health issues that I can answer on the air?

>> You may write me via the Internet at matters of the mind at all.

One word at WFA ECG.

>> I'm psychiatrist Jeff Oliver and you've been watching Matters of the Mind on PBS Fort Wayne God willing on PBS willing.

>> I'll be back again next week.

Have a good evening.

Good night