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>> Good evening.

I'm psychiatrist Jay Fawver live from the Brucey in studio in Fort Wayne , Indiana.

Welcome to Matters of the Mind now in its 10th 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 a call in the Fort Wayne area by dialing (969) 27 two zero or if you're holding a place else coast to coast you may dial toll free at 866- (969) to seven to zero.

>> Now on a fairly regular basis we are broadcasting live every Monday night from our spectacular PBS Fort Wayne studios which lie in the shadows of the Purdue Fort Wayne campus.

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

>> It reads during a favor I have been referred to an online psychiatrist.

What are some things that I should be aware of if I choose to see a medical provider that way?

>> One online psychiatrist?

Well that's kind of work I do.

It's called Telehealth and the online psychiatrist will see you by video and you want to make sure that your videos work and your audio's working.

Your speakers are on so make sure the technology's all in place first and foremost and a lot of online psychiatry will have you complete questionnaires if they have that kind of telehealth platform.

Now in my practice we have as many as 15 different questionnaires for the first evaluation to get to know some of your background and ask you questions on the questionnaires that we'd be asking during the appointment anyway.

>> So what do you need to get together yourself?

Well, number one, I think something very important would be kind of conceptualize what kind of symptoms have been bothering you over the course of time.

>> What are your main treatment goals?

How would you want to feel better and in doing so write out different things that you might be concerned about in terms of treatment.

Would you want to have medication treatment, counseling, treatment?

>> Do you have any particular apprehensions about any medications?

Secondly is extremely important for any psychiatrist online or in person to know your past medication history background what medications have you taken?

>> How do they do for you and to know as much detail about your past medications as possible?

It's very important.

So you want to know ideally the dosage when you took them what what combination you might be used.

>> Did you have any good effects?

Did you have any bad effects?

Why did you stop them some people stopped medication because we're feeling really good.

That's wonderful.

We won't want to go back to that medication.

Other people stopped their medication because it's not working and sometimes because it's intolerable.

So we want to know that kind of information.

It's also very important with an online psychiatric appointment to know about your family histories, background with mental health issues and their treatment if you can find out.

>> So if you have a mother or father, sister or brother who have been treated with certain medications for similar symptoms that you are now experiencing by all means we want to know all about that.

>> And if your primary care doctor has been involved with your treatment, has the primary care doctor done any labs for you including not only thyroid test glucose test ion tests but sometimes genetic testing?

>> So if you've had genetic testing, the online psychiatrist would want to know those type of things.

But there's a lot of different things different strategies online psychiatrists might have for you but try to make sure your technology is working ahead of time and try to make the most of the appointment.

>> Thanks for your email.

Let's go to our first caller our first caller is from Jenny.

>> Hello Jenny.

Welcome to Mastermind Jenny.

You had mentioned that you have a mood problem.

You want to know whether you should be treated by a psychiatrist or a family doctor?

Well, you might not have much of a choice, Jenny, because over the next five years it's projected we're going to have about 27 percent fewer psychiatrists right now family doctors are treating about 80 percent of depression that's being treated now it's estimated that half the people out there with depression are getting treated him the half who are getting treated, 80 percent of those are four out of five of those people are getting treated by their family physician.

>> Why?

Well, it's because there aren't that many psychiatrists out there, many psychiatrists are going on to inpatient or hospitalization work.

>> So you might not be able to see a psychiatrist over these next few years.

Who do you see in the mental health or the psychiatric side?

Often it's going to be a nurse practitioner sometimes a physician's assistant and nurse practitioners.

>> It's it's our job as psychiatrist to try to get nurse practitioners well trained as well as our family medicine colleagues, family medicine colleagues who are physicians and nurse practitioners, physician assistants in family medicine.

>> So it might be a matter of availability and now there are some big cities Boston, Washington DC, Dallas who have plenty of psychiatrist.

>> Miami has a lot of psychiatrists but in most areas like northeastern Indiana there are fewer and fewer psychiatrists becoming available and you might not be able to see a psychiatrist over the course of time.

>> So the question would be would your primary care clinician, your nurse practitioner and primary care would your primary care physician do they feel comfortable treating mood disturbances?

>> You might want to ask them about that right up front.

Thanks for your call.

Let's go next caller.

Hello Jack.

Welcome to Bear in mind, Jack, you want to know does anxiety cause white coat syndrome?

A white coat syndrome Jack is where somebody walks into a room and used to clinicians would wear white coats and the white coats would cause a lot of anxiety just in the white coat .

>> So yeah, if you're already kind of anxious and you're anxious about a blood pressure that you might get as you tense up your heart rate can start racing and your blood pressure can increase sometimes you have to calm down for about five or ten minutes before you actually get your blood pressure checked.

So I would suggest trying to get your appointment a little bit earlier and be able to relax in the lobby before you actually see the white coats usually its first from a medical assistant or a nurse who will typically room you and see you first.

You want to get to the appointment a little bit earlier if you're running late to an appointment or if you have an Arason from the parking lot, that in itself will increase your anxiety by your heart rate, increasing your blood pressure increasing and the question would always be OK upon seeing somebody in the mental health field or the medical field in general, is that going to cause you anxiety because you wonder what they're going to say in response to your current symptoms?

>> So anxiety itself can be part of the so-called white coat syndrome.

>> Thanks for your call, Jack.

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

Our next e-mail question reads Dear father, I have a friend that said people with anxiety love Halloween.

Is that true?

If so, why?

>> I'm not really sure Halloween is a we do we want to call it a holiday is it's a means of celebration of the fall.

>> People like to dress up.

They like the excitement behind it.

Yeah, there's about a two week lead up to Halloween and during that two week lead up there's anticipation of the Halloween night itself where people might have as we know a lot of candy, there's a lot high rate of diabetic ketoacidosis in the emergency rooms I understand during Halloween night because people gorge on candy so what's the excitement about Halloween?

>> Yeah, it's part of it.

It's just being fall.

People are out and about getting some fresh air and those type of things.

But I wouldn't say necessarily people with anxiety are particularly prone to liking Halloween.

I'd want to know some clarification from your friend on on that observation.

So thanks for your call.

>> Let's go to our next call.

Let's go to our next caller here.

Our next caller is from Jim.

>> Hello, Jim.

Welcome to mastermind Jim.

You've mentioned you're taking Zoloft for depression doesn't seem to be working anymore.

>> Why are the medications could I suggest why you want to go a whole different directions ?

>> Zoloft is a medication that mainly increases serotonin secondarily increases dopamine a little bit Zoloft also known as sertraline as a medication has come out since nineteen ninety two but for a while has a calming effect.

Zoloft has a lot of uses for anxiety conditions like obsessive compulsive disorder, generalized anxiety disorder, panic disorder, social anxiety disorder so it can help with the spectrum of anxiety conditions because increasing serotonin can give you a bit of a calming effect in settle on your nerves some it'll also help with crying and some people.

However, Zoloft sometimes will make people feel blah.

We call it emotional blunting but you don't feel happy.

You don't feel sad.

You just feel kind of blah.

It can also sometimes to some degree blunt the ability to concentrate just a little bit.

So if Zoloft not working my first question is in what way is it not working?

But my second question is what was the original intention for its use if the original intention for its use was primarily to help with anxiety, we might go a different direction for anxiety.

But if you're using it primarily for sadness, lack of enjoyment of things, poor motivation and you might want to go to a whole different class of medications.

>> Right now there are over 30 different classes of medications and will choose from those different classes of medications based on their mechanism of action often trying to match up a person's symptoms with what medication might do best for them.

So the symptoms are called phenotype and then we try to use the phenotype symptoms as a means of matching up which kind of medication class might be helpful.

And as we often see with high blood pressure diabetes treatments, asthma, other medical conditions, you're often going to use a combination of two sometimes three different medications to try to meet your goals.

We do the same thing in psychiatry.

We might use two or three different medications that have different mechanisms of action to try to best treat your symptoms.

>> So let's say a Zoloft you're getting less than twenty five percent benefit for treating depression as an example less than twenty five percent benefit.

>> I'd probably bail and have you go off of it if it's between twenty five percent up to maybe 50 percent we can sometimes add another medication to the Zoloft to try to take you over the finish line and get you up to 90 percent benefit if it's over fifty percent benefit sometimes some clinicians will simply increase the dosage.

However there's not a lot of good data out there showing that simply increasing the dosage on a lot of these antidepressants does you that much more good compared to adding on something else.

It has a different mechanism of action so sometimes it's a matter of one medication giving you the benefit up to twenty five percent or 50 percent then adding on another then another medication to give you that benefit up to 75 or 80 sometimes adding a third medication to get you up to 100 percent.

The ideal the the ideal scenario would be to take as few medications as possible but it used to be thought that a high dosage of one medication would be the best way to go as back in the 1990s.

>> But since that time we've talked about more combined rational psychopharmacology where you're combining low doses of medications in different classes to try to get your best benefit as opposed to a high dosage of one medication .

>> So different mechanisms of action might be more helpful for you but talk it over with your prescribing clinician about the Zoloft.

In what way is it not helping you?

You know, Zoloft not going to help people that much if they have a condition like bipolar disorder where they have highs and lows, you need a mood stabilizer in those cases it's not going to help you if you have undiagnosed diabetes for instance, if you have blood sugars that are sky high that's sometimes not identified until you have a heart attack or a stroke or some medical catastrophic event.

But if you have blood sugars are way out of control that needs to be addressed.

>> We commonly see undiagnosed sleep apnea where somebody says their medication is not working.

We find out their snoring.

They feel tired all the time.

They might even pause and they're breathing at nighttime while they're sleeping.

>> And for those people they need to have continuous positive air pressure or automated positive air pressure.

Apapa keep up these patients are not getting adequate airflow to their lungs and thereby not enough oxygen to the brain at night.

So they need a different means by which they can help the brain function so first question will always be what are we treating because you've got to know you're treating if you're treating something that doesn't respond adequately to Zoloft by itself you need to go a different direction and we hear the same kind of condition if you go to the emergency room and you have chest pain, the E.R.

doctor or the E.R.

clinician needs to try to sort out what's causing the chest pain.

Is it a heart attack?

Is it gastroesophageal reflux?

Is it a pulmonary embolus?

Is it pneumonia?

What's causing the chest pain itself because your treatment for the chest pain is going to be entirely different based on the underlying condition that might be evident and the same as in psychiatry.

>> We have to be accurate in diagnosing what the problem may be if your anxiety is related to trauma especially trauma prior to the age of eight years old, we might treat that differently as opposed to anxiety related to trauma that occurred last week from a motor vehicle accident.

If you had a traumatic experience last week from a motor vehicle accident and you're having symptoms of post-traumatic stress, we might give you something as simple as a beta blocker to try to settle down the anxiety right off the bat that's ideally given within the first 48 to 72 hours.

But if it's been a week and you're still having a fast heart rate, you're still shaky.

We might give you a beta blocker.

>> We wouldn't do that for so many necessarily who had repeated trauma prior to the age of eight years old.

>> So it's important for us as mental health clinicians to try to dissect through all the symptoms what might have contributed to them, how long they've been going on, how often they occur because you could have trauma when you're a small child here you are.

>> Thirty five years old if it's not bothering you that much and you're having trouble with depression but it's not apparently related to trauma, we might not treat you specifically for the trauma itself.

We might go a different direction so we have to sort it all out as mental health clinicians while not taking our eye off the possibility that there might be an underlying medical condition causing a lot of the difficulties because undiagnosed medical conditions obviously can contribute to psychiatric disturbances and we need to do something about that.

We need to take a close look at your medications with your medications, your medication like Zoloft certainly.

And I might not work if you're also taking St.

John's Wort for instance and you're not telling us about it if you take in St.

John's Wort that's an herbal product that was very popular back in the 1990s.

It's from a plant that turns has a very pretty yellow blossom on it and it's called St.

John's Wort St.

John's Wort Wort meaning plant in German, German and St.

John's Wort blooms around the first week of June and it's thought that that was the birth date of John the Baptist I believe it was so that's kind of how they came up with St.

John's Wort but St.

John's Wort has an antidepressant feature itself.

>> Some people will take St.

John's Wort because it's easy to get it's not a prescription product but it tends to chew up or increase the metabolism of a lot of medications and make basically not work including including oral contraceptives or birth control pills.

So a lot of women back in the 90s they heard about St.

John's Wort and it was on the cover of Newsweek one week back in the 1990s as up and coming antidepressants when people were excited about St.

John's Wort.

>> However, it was found to increase the metabolism of a lot of other medications making the not work and some women got inadvertently pregnant, taken their birth control pills on a regular basis but then they took St.

John's Wort on top of their birth control pills, birth control pills didn't work so we have to consider drug interactions with medications you might be taking even supplements in some cases.

>> So we want to know as much information about that.

But keep in mind there are right now over 50 different antidepressant medication combinations that we can utilize so a lot of different options out there if Zoloft for whatever reason wasn't working for you.

>> Thanks for your email.

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

Our next e-mail question reads Dear Doctor Father, I have more carbohydrate cravings when the cooler weather comes and I find myself overeating in the fall and winter, what's the link between the changing seasons and appetite?

>> It might be darkness.

I saw a person a day who gets depressed every October or November and it goes all downhill from there until about April and that's classical seasonal exacerbation of depression.

So if you have seasonal affective disorder now we call it major depressive disorder with seasonal exacerbation if you have a worsening of your depression somewhere between October and March, that means that it's probably the darkness of the and decreased light that's affecting you and what happens there you're died the back of your eyeballs will sense the amount of light coming day by day by day.

So you'll notice in the morning it gets darker and darker and the evening it's getting darker and darker earlier and earlier.

And what's happening there?

You're getting less light to the retina and I will transmit that light signal to this little body in the middle of the brain here called the pineal gland.

It's a p shaped gland pineal gland that secretes melatonin and the light from the sunlight for that matter and the outdoor light will give that signal to the pineal gland if it's dark pineal gland secretes more melatonin and indirectly the brain will receive less serotonin.

>> Why do you eat more carbohydrates when you're stressed out and when it's getting dark or outside it's because your brain is sensing a disturbance and serotonin carbohydrates will increase the transportation of tryptophan into the brain.

>> Tryptophan needs to be carried in the brain.

Tryptophan is an amino acid and tryptophan needs to be carried into the brain and with increasing carbohydrates with the increase insulin insulin increase the transport of tryptophan into the brain tryptophan turns into serotonin .

So one way you can indirectly without a medication under your clinician supervision of course one we can indirectly increase serotonin would be to take a trip to feed supplement and then add another supplement to it that would be vitamin B6 if you want the active form of vitamin B6 you might have heard about a particular supplement called P five P but P five P is the active breakdown product of vitamin B6.

>> Vitamin C B6 will enhance the transportation of tryptophan into the brain to manufacture serotonin so decreases serotonin are thought to be related to the dark days of winter.

Dark days of winter instinctually will make you tired, sometimes irritable, a little bit anxious and your brain is saying I need more serotonin up here any more serotonin up here.

So you're craving carbohydrates to try to jack up the insulin levels because insulin will then create more tryptophan transport transport into the brain itself.

We'll hear about the same phenomenon occurring during the premenstrual days for women.

Women will go five days, sometimes even fourteen days before their periods and have an increased craving for carbohydrates.

The reason for that is because with the ups and downs of estrogen and progesterone it'll cause decrease in serotonin in the brain indirectly.

That will cause you to increase carbohydrates during the premenstrual day.

So we'll hear about that with a premenstrual days for women and we hear about this carbohydrate craving especially in the wintertime.

What do you do about it?

No one try to get more exercise.

Exercising will increase serotonin dopamine, norepinephrine transmission the brain favorably.

So increasing exercise especially in the wintertime.

I know you don't feel like going out and exercising in the wintertime.

Go to a gym, do something for 30 minutes, five days a week at least get some kind of physical activity and exercise something else that enhances serotonin quite frankly is socialization.

Increasing socialization can help with bonding, enhancing bonding from social interaction can increase serotonin.

So that's a nice natural way to do it.

You know, I don't often recommend supplements for a lot of people but if you want to take a supplement during the wintertime and you're noticing that you're feeling more tired ,yeah, you can take the tryptophan P five P combination under your clinician's guidance but also quite frankly something is very natural and very safe is to get a bright light box.

A light box goes for about two hundred dollars but it's a bright light box where it's giving you this intense white light.

It's not any particular spectrum, just a bright white light.

It basically wakes up the brain.

It will inhibit the pineal gland from from secreting melatonin and a light box where you sit in front of it.

It's about a foot or two away sit in front of it for about 20 to 30 minutes every morning wakes up the brain.

That in itself has been very helpful for many, many people with seasonal affective disorder or winter depression and it can actually decrease the craving for serotonin producing chemicals like the tryptophan and that's why you increase the carbohydrate consumption.

So as we go into the winter I wish you Beth's best with that but try to exercise socialize some and you might want to consider especially that light box if you noticing you feel lousy historically every single winter.

Thanks for your call.

Let's go to next caller.

>> Hello Marge.

Welcome to Matters of the Mind.

Marge, you had mentioned your child is starting first grade has been diagnosed with ADHD Attention Deficit Hyperactivity Disorder.

What medications would you like me to suggest?

>> OK, what what medications can I suggest?

It depends on the type of ADHD Marje.

>> It also depends on what other family members have been treated with ADHD if any and what medications have they done well on are not so done so well on.

So I'm going to ask OK, if you have anybody with ADHD, the first thing I want to know is how is it affecting their lives being a little bit hyper being highly energetic as a six year old or so you want to sort out how is that different from that child's peers?

So the problem with ADHD is it could be very disruptive in a classroom setting.

So what are the options?

Could the child be homeschooled?

Could the child be in Montessori?

Could the child be in some kind of classes where the ADHD wouldn't necessarily be to their disadvantage?

>> But many children in classrooms when they have to sit there with twenty other kids, thirty other kids in some cases that ADHD something was somewhat problematic in terms of does not disrupting the classroom but I'm able to pay attention to their needs.

So if they were to use a medication as you had mentioned they were to use medication.

I want to know first off right off about what medications, if any have any other family members taken for ADHD specifically sometimes that will just allow you to hit the home run because of a family member has responded to this medication or this medication that's the medication typically want to go to use often at a low dosage for a child.

But you want to start with a mechanism of action that another family member has found beneficial.

There are many, many different stimulant and non stop medications for ADHD medications work and over 90 percent of cases for ADHD we have the hyperactivity in impulsivity which many six year olds will apparently have.

But you also have to sort out OK to what degree is that impairing to their academic progress, their socialization, their ability to get things on a day to day basis.

>> So you got to sort out to what degree is it impairing.

But if you are to use a medication like you know, you want to sort out the pros and cons, be behind the nonsense what medications they work in about 60 to 70 percent of the cases.

But the what medications often will work better for worry and a lot of anxiety now you always have to remember with ADHD or attention deficit disorder itself, worry and anxiety often go hand in hand because especially as you get older you're not getting things done.

You're procrastinating, you're putting things off, you're not completing projects and creates a lot of anxiety unnecessarily.

So if you treat the underlying attention deficit disorder or the hyperactivity component to that you can actually decrease the anxiety that goes along with it.

>> Thanks for your call.

Let's go to our last caller.

>> Hello Hello Kitty.

Welcome to Mars.

The mind if you want to know when does borderline personality disorder first made itself manifest itself in and in person and what can be done about it be borderline personality disorder is a condition where I think is goes along the lines of what's called bipolar spectrum disorder with borderline personality disorder people will have abrupt shifts, abrupt shifts, shifts in their mood where they will get angry or irritable and they'll have moodiness that's provoked by a situation or an interpersonal conflict.

So they're very prone to having difficulty with anxiety trust they can actually get a little paranoid to when things are happening around them but they come out of a very quickly it's a little bit different from bipolar disorder but it does affect their mood.

It's first manifested words.

I think you can really diagnose it and maybe early 20s.

But I want to be careful because the brain is still developing until you're 24 years of age.

So your impulse control, your ability to cope with different things might not might not be fully established until you're about twenty four or so in my practice I typically will wait until somebody is in her mid 20s before I really definitively diagnose them with borderline personality disorder often addressing their treatment with mood stabilizers.

>> Candy, thanks for your call.

Unfortunately we're 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 that matters the mind at WWE dot org I'm psychiatrist Jeff Offering.

You've been watching matters of mine on PBS Fort Wayne now available on YouTube God willing and PBS willing.

>> I'll be back again next week.

>> Thanks for watching.

Goodnight