• The findings from a new study suggest that arthritic pain has a strong emotional component that is not present with experimental pain conditions.
  
  The results indicate that the cingulate cortex, thalamus, and the amygdala -- brain regions known for the role in processing fear and emotions -- are highly active during arthritic pain.
  
  The study demonstrates the importance of the medial pain system during the experience of arthritic pain and suggests that it is a likely target for both pharmacologic and nonpharmacologic interventions.
  
  Both the arthritic pain and experimental pain states activated the entire pain matrix in the brain. However, as stated, arthritic pain was also associated with heightened activation of the medial pain system, including the cingulate cortex, thalamus, and the amygdala.
   
• A cognitive-behavioral intervention among people living with HIV significantly reduces the risk of HIV transmission. HIV transmission risk was reduced by 36% in the intervention group, compared with the control group, at the 20-month assessment. However, the treatment effect in terms of a reduction of HIV transmission risk acts was not maintained at 25 months.
  
  Even small behavior changes among infected individuals can have a significant effect on the epidemic. This suggests that the behavioral intervention used in this study "can be effective in reducing the number of new HIV events.
  
  J Acquir Immune Defic Syndr 2007;44:213-221.
   
• Among patients with coronary artery disease, comorbid diabetes or depression increases the risk of dying from heart disease. The risk is even higher when both diabetes and severe depression are present. Depression increase the risk associated with diabetes.
  
  Depression and diabetes were independently associated with increased mortality. Among diabetics with coronary artery disease, having severe symptoms of depression further increased the risk by roughly 25%, the investigators report.
  
  The bottom line is that the excess risk is confined to diabetic patients with coronary artery disease and moderate-to-severe depression.
   
• The costs of untreated insomnia far outweigh the costs of not treating this common disorder, which affects 10% of the US population. Medications cost less than $200 per year for the typical insomnia patient vs $924 to $1143 more in medical expenses in the 6 months before treatment initiation.
  
  It costs far less to treat insomnia than to ignore it. Untreated insomnia affects individuals' health, quality of life,and job performance and increases their use of healthcare services substantially. The typical approach used to assess the burden of insomnia has been has been to focus on the current cost of treatment. Looking at costs of untreated insomnia may be more informative.
  
  Unlike many other medical conditions, insomnia is not an expensive condition to treat. The investigators found that combined direct and indirect medical expenses for younger patients were $1253 higher for those eventually diagnosed with insomnia compared with controls without insomnia.
  
  Sleep. 2007;30:263-273.

• A type of cognitive-behavioral therapy (CBT), in which a patient repeatedly recounts traumatic events, appears to be effective in treating female military personnel with posttraumatic stress disorder (PTSD). This "prolonged exposure technique was more effective than "present-centered" CBT, which is more emotionally supportive with a focus on current life problems as manifestations of PTSD.
  
  Women in the prolonged therapy group had lower CAPS (Clinician Administered PTSD Scale) scores than the present-centered group). The secondary outcomes were "loss of diagnosis (no longer meeting symptom criteria and CAPS severity score. Prolonged exposure was more likely to result in loss of diagnosis than was present-centered therap. Those in the prolonged exposure group were also more likely to achieve total remission
  
  JAMA 2007;297;820-830.
   
• Among people who experience a major disaster, smokers are more likely to develop mental health disturbances than those who don't smoke.
  
  "Post-trauma mental health disturbances such as post-traumatic stress disorder (PTSD) are associated with increased smoking, either by starting to smoke or an increase of tobacco use. However, very few trauma studies examined the reverse relationship, i.e., whether smoking is a risk factor for PTSD or other postevent mental health disturbances."
  
  This may suggest that disaster victims who smoke have the opportunity to reduce the risk for postevent mental health disturbances when they quit their smoking behavior after the disaster.
  
  J Clin Psychiatry 2007;68:87-92.
   
• People who are at risk for personality disorder are also at risk for cardiovascular disease, independent of socioeconomic or lifestyle factors.
  
  Research found significant associations between any personality disorder and stroke and any personality disorder and ischemic heart disease after adjusting for potential confounders.
  
  After adjustment, stroke was significantly associated with avoidant, obsessive-compulsive, and borderline personality disorders. Significant associations were observed between ischemic heart disease and avoidant, paranoid, schizotypal, schizoid, and borderline personality disorders.
  
  J Clin Psychiatry 2007;68:69-74.
   
• Children with severe mood dysregulation differ behaviorally and psychophysiologically from children with bipolar disorder.
  
  Diagnostic criteria for severe mood dysregulation include anger or sadness that is present most of the time, on most days, combined with hyperarousal and increased reactivity to negative emotional stimuli.
  
  They are prone to violent outbursts, temper tantrums, and aggression, but have no episodes of euphoria. In contrast, children with bipolar disorder have periods of mania and depression.
  
  Deficits in the children with severe mood dysregulation closely resemble deficits observed in patients with oppositional defiant disorder.
  
  You should not necessarily assume that a child who is very irritable with attention deficit disorder has bipolar disorder. Instead of treating them with mood stabilizers, children with severe mood dysregulation may do better with stimulants.
  
  Am J Psychiatry 2007;164.
   
• Depression and anxiety are common in HF outpatients. Psychosocial distress, including depression, anxiety, and social isolation, are related to mortality in this patient population; depression and social isolation predict mortality independent of demographic and clinical status and perceived functional status.
  
  Discrepancies between findings about the relationship of psychosocial factors to mortality of HF inpatients and outpatients suggest that psychosocial distress differs in patients during acute and chronic HF. Psychosocial distress is associated with mechanisms that increase mortality; improving depression, anxiety, or social support might reduce chronic HF progression or mortality. Attention to assessment and management of psychosocial issues is important in patients with chronic heart failure.
   
• Patients with dementia associated with Parkinson's disease (PDD) often experience neuropsychiatric symptoms - and these symptoms differ from those associated with other types of dementia.
  
  Patients in the psychosis and agitation clusters had the lowest Mini-Mental State Exam scores and the highest Unified Parkinson's Disease Rating Scale score. These two symptom clusters were also associated with the highest distress scores in caregivers.
  
  Subgroups of patients with PDD based on the neuropsychiatric symptom profile has been proposed with potential treatment implications. They also suggest there may be "specific neurobiological changes underlying the different neuropsychiatric clusters.
  
  J Neurol Neurosurg Psychiatry 2007;78:36-42.
   
• "Patients with chronic obstructive pulmonary disease (COPD) who suffer from depression have poorer survival, suggesting that antidepressant or psychological interventions in depressed patients with COPD may improve outcomes.
  
  Depressive symptoms are common among patients with COPD, but depression's impact on COPD outcomes had not been fully investigatedt.
  
  Depression was associated with an increased risk of death independent of COPD severity, comorbidities and behavioral, psychosocial and socioeconomic factors.
  
  Depressed COPD patients compared with non-depressed COPD patients had longer hospital stays during the index admission well as the total number of days hospitalized in 1 year.
  
  Interventions that reduce depressive symptoms may potentially affect COPD outcomes."
  
  Arch Intern Med 2007;167:60-67.
• Higher hypothalamic-pituitary-adrenal (HPA) axis activity, as reflected by increased levels of plasma cortisol, is associated with more rapid disease progression in patients with Alzheimer-type dementia. Studies of subjects with dementia of the Alzheimer type have reported correlations between increases in activity of the HPA axis and hippocampal degeneration.
  
  In patients with dementia, higher plasma cortisol levels were associated with more rapidly increasing symptoms of dementia. Higher plasma cortisol levels were also linked to more rapidly decreasing performance on neuropsychological tests associated with temporal lobe function. No such associations were observed with non-demented subjects.
  
  Plasma cortisol levels were not associated with clinical and cognitive assessments obtained at the single assessment closest in time to collection of plasma. This suggests that "increased cortisol levels were associated with more rapid rates of disease progression rather than the severity of disease.
  
  The findings fit with the hypothesis that stress increases glucocorticoid levels and accelerates Alzheimer's disease progression. If so, it would give impetus to therapeutic approaches ... to decrease stress and levels of stress-related glucocorticoid hormones, the researchers conclude.
  
  Am J Psychiatry 2006;163:2164-2169.
• More than a third of patients with obsessive-compulsive disorder (OCD) who are receiving recommended doses of selective serotonin reuptake inhibitors (SSRIs) do not perceive sustained long-term benefit from the treatment. Few OCD patients receive the recommended doses of cognitive-behavioral therapy (CBT). The short-term efficacy of pharmacotherapy and behavioral interventions for OCD is well established.
  
  In the current study, the researchers studied 293 adults with primary OCD. Overall, 182 subjects (78%) were taking recommended doses of SSRIs at intake. Of these, 112 (62%) rated themselves as being very much or much improved. The remaining 70 subjects rated themselves as minimally improved, unchanged, or worse while taking the recommended doses of SSRIs. These patients had been receiving their current SSRIs for a mean of 2.7 years.
  
  Forty-two subjects were receiving SSRIs and a neuroleptic augmentation. Of these, 12 (29%) reported a response.
  
  A total of 111 patients (38%) received at least the recommended 13 lifetime sessions of CBT. Although the mean number of sessions was 37, only 71 patients (24%) reported completing a continuous course of 13 weekly sessions.
  
  Of 27 patients who received a course of CBT in the past year, 18 (67%) rated themselves as very much or much improved. Sixty-eight percent of patients who received the recommended course of 13 weekly sessions rated themselves as responders, compared to 47% of those who received less than the recommended dose. J Clin Psychiatry 2006;67:1713-1720.

©2006 David B. Adams, Ph.D.