December 25, 2000
Q
"I worry about my husband's health. His father has Alzheimer's
and my husband seems stressed out trying to care for his father?"
A
Researchers have found that the stability of the IgG antibody response
to a bacterial pneumonia vaccine is inhibited in older adults who live
with chronic stress.
They found that psychological stress
associated with caregiving for an Alzheimer's patient...modulated the
immune response to the pneumococcal vaccine.
Based on an analysis of blood samples
obtained before pneumococcal vaccination and again at 2 weeks, 3
months and 6 months after vaccination, the researchers found that the
current caregivers had a lower antibody response to the vaccination
than the former caregivers and controls. Although initially all three
groups had similar antibody responses, after 6 months current
caregivers had lower antibody titers.
The investigators believe that chronic
stress in current caregivers either produces physiological changes in
the immune response, resulting in fewer IgG-producing B-cells, or
B-cells are unable to maintain IgG synthesis over time. In any case,
they believe that this is "the first evidence that chronic stress
can affect the stability of IgG antibody levels to a bacterial vaccine
over time."
In spite of the increase in data on the
effects of stress on health, managed care is limiting the ability of
our healthcare system to deal with stress.
Psychosom Med 2000;62:000-000.
December 18, 2000
Q
"Should I be consulting my
family physician for my depression or see a psychologist?"
A
You should do both. A recent
article states that "Depressed
patients who receive nondirective counseling or cognitive-behavior
therapy improve significantly more than similar patients who receive
general physician care, but only up to 12 months, according to a
report to published in the December 2nd issue of the British
Medical Journal.
During the 12-month study period, the
authors found that depression scores improved significantly in all
groups over time. However, at 4-month evaluation, Beck (depression)
scores had improved more in patients who underwent cognitive-behavior
therapy or non-directive counseling than patients who underwent
general physician care.
Throughout the study, there was no
significant difference in depression scores between patients who
received either form of psychological therapy. At 12 months, all study
participants had similar Beck depression scores.
A cost comparison of the three
treatment options revealed no significant differences in direct costs,
production losses, or societal costs at 4 or 12 months."
BMJ 2000;321:1383-1392.
December 11, 2000
Q
"We
have just had a patient who committed suicide. When I was in school,
it was believed that there was greater than a 10% risk of suicide in
depressed individuals. What is the current thinking?"
A
To
quote from a recent article: The 30-year-old assumption that a
diagnosis of depression carries with it a 15% lifetime risk of suicide
is incorrect according to the authors of a study in December's American
Journal of Psychiatry.
The lifetime risk of
suicide is 8.6% for depressed patients who had been hospitalized for a
suicide attempt or ideation, 4% for depressives hospitalized for
reasons unrelated to suicide, and just 2% for outpatients.
What also makes the 15%
statistic inaccurate is that depression is a more common diagnosis
than it used to be, the authors contend. Today up to 20% of the
population meet criteria for a watered-down, broad, and, ultimately, a
less lethal depressive diagnosis. In contrast, the prevalence of
depression in the 1970s was only 2-3%.
Depressed patients still
have a much higher risk for suicide and suicidal behavior than the
general population.
The main point is that the
risk of suicide with depression is real, substantial, and higher than
a nondepressed sample -- but not as high as previously reported
because of the populations studied. Depression can be fatal. "
December 4, 2000
Q
"I, like all parents, are concerned about my teenage children.
What is the current thinking regarding kids who will have problems in
their adolescence."
A
School failure and peer
influences are much better than race or income as predictors of which
teenagers will engage in high-risk behaviors such as smoking,
drinking, and violence.
Researchers wanted to see which
teenagers had ever smoked, drank, had intercourse, thought about or
attempted suicide, or been involved in weapon-related violence
(carrying or using a weapon, or witnessing those behaviors). The study
results are published in the December issue of the American
Journal of Public Health.
The researchers found that, although
national trends have been showing improvement, there are still a large
number of teenagers engaging in these high-risk behaviors. For
example, more than 9% of teenagers said they had used a weapon against
someone in the past year, and 25% had smoked a cigarette within the
past 30 days. More than one in seven 7th and 8th graders said they had
had sex already.
But the factors that most people assume
are associated with these behaviors, such as being a member of a
minority group, being poor, or living in a single-parent household,
end up not being very predictive. For example, those three factors
accounted for only 0.5% of teenagers who had attempted suicide and
9.7% (the highest percentage for any behavior) of those who had had
intercourse.
Instead other predictive factors
emerged: school failure, lots of unstructured free time, and what
activities the teens' friends engaged in. These factors explain 20% to
50% of behaviors. "
November 27, 2000
Q
"I am worried about my teenager beginning to smoke. Her friends
do. She knows the risk, but she tends to always be first to seek
adventure and risk. Are there any data about those teens most likely
to smoke?"
A
The personality characteristic of sensation seeking (the tendency to
seek varied, novel, complex, and intense sensations and experiences)
is associated with a greater risk of smoking, and this may be due to
greater initial sensitivity to nicotine.
The study, which was published in the
November issue of Experimental and Clinical Psychopharmacology,
found that those scoring high on sensation-seeking personality
measures were more sensitized to nicotine's mood altering influences
when the nicotine dose was at the lower level tested (10 mg/kg). This
dose mimics the level of nicotine likely obtained by teens
experimenting with smoking. If similar results are seen with teenagers
during early tobacco experimentation, interventions focused on teens
high in sensation-seeking traits may help with smoking prevention
efforts.
The researchers found greater responses
to nicotine's subjective effects in nonsmokers who had higher
sensation-seeking personality scores. The results, say the authors,
are very similar to findings of other studies involving d-amphetamines
and suggests that "the increase in sensitivity to drugs due to
sensation seeking may be broad and not specific to nicotine."
Very few relationships were found
between sensation seeking and subjective responses to nicotine in
smokers, which provides evidence that this personality type is related
to initial, and not general, sensitivity to nicotine.
As expected, the researchers did not
find a significant association between sensation seeking and heart
rate and blood pressure responses to nicotine in nonsmokers. This
suggests, say the authors, "that this personality characteristic
is not related to all nicotine responses but may be specifically
associated with mood altering experiences and other effects that may
be relevant to nicotine reinforcement."
Exp Clin Psychopharmacol. 2000;8:462472
November 20, 2000
Q
"My husband has been
diagnosed with insulin dependent diabetes. This is recent, and he is
very depressed. I believe his response is excessive. Are there any
data about this?"
A
Empirical studies
"strongly suggest that depression is more prevalent among adults
with diabetes than among the general population." However,
according to a review of the subject in the October issue of Diabetes
Care, the reasons are not fully understood.
They found that the initial onset of a
major depressive disorder "seems to be independent of the onset
of type 2 diabetes, but results remain equivocal for type 1
diabetes." Also, the researchers observe that when major
depressive disorder is involved, this may increase the probability of
the development of type 2 diabetes.
Furthermore, there is accumulating
evidence that major depressive disorder "has a higher recurrence
rate, and depressive episodes may last longer in individuals with type
1 or type 2 diabetes." Other studies have shown improved diabetes
control after remission of major depressive disorder.
In addition, they conclude, the
apparent interaction between biological and psychosocial factors may
increase "the likelihood of developing diabetic complications,
which further add to the complexity of the phenomenon."
Diabetes Care
2000;23:1556-1562.
November 13, 2000
Q
"My daughter has an eating disorder. She once volunteered for
treatment, but the benefit was short-lived. Should we force her into
treatment at this time. She is quite ill, and we fear for her
survival."
A Trying
to help a person who doesn't want help for a problem is often an
exercise in futility. However, in the case of eating disorders,
involuntary treatment seems to be as effective in the short-run as
voluntary treatment is.
Involuntary patients restored weight
and were able to return home. Many of them also said they understood
they were sick and needed treatment.
Watson added that while involuntary
treatment can be controversial, no detained patient took any legal
action or registered any type of complaint. Numerous safeguards are
also in place within the state to protect the rights of people
committed involuntarily for medical treatment.
The researchers found that the
involuntary group of patients had more previous hospitalizations, an
indication of their resistance to treatment. They also scored slightly
lower on certain tests that measure how well a person understands what
is going on around them and how their actions affect their lives.
Am J Psychiatry.
2000;157:1806-1810
November 6, 2000
Q
"Don't health car providers develop psychological disorders? You
certainly don't hear much about it."
A
Although substance abuse
has been a recognized problem among physicians, little is known about
the prevalence of other disorders in this population. Mental disorders
among physicians may be more common than is recognized.
Since 1989 there have been
only 11 reports in peer-reviewed medical journals specifically about
the subject of mental illness among physicians. This is to be
distinguished from articles about "physician impairment" --
commonly understood to refer to substance abuse -- for which there
have been approximately 80 articles
Among doctors admitted to
an impaired physicians program, 26-48% of the admissions were due to
major depression, anxiety disorders, and narcissistic personality
disorder. Narcissistic personality disorder is implicated in relapse
among doctors with substance abuse disorders.
Early in training
physicians are taught to think they can't ask for help, so it is
common for them to treat themselves. But it can be very destructive.
Individual physicians, and organized medicine, lack a language for
speaking about mental illness.
October 30, 2000
Q
"My job...the setting...the people...my tasks...really stress me
out. I wonder if many, most or all people feel that way...or is my
situation atypical?"
A
The UK mental health charity Mind
has found that work stress and loneliness are thought to be the
biggest causes of mental health problems today, in a survey of the
charity's financial donors.
Work stress came out as the most
significant stress and voters in the survey are over 55 and they
have a good perspective of life. Their vote shows that work stress
today is real and is not just a trendy '90s disease.
Sixty one per cent of respondents cited
"work stress" as the most common cause of mental health
problems, with "loneliness" rating a vote of 59%.
"Bereavement" ranked third at 55% and "traumatic
stress" ranked fourth at 52%.
Also, more than half of those surveyed
thought "children growing up in the next decade will be more
vulnerable to mental health problems than [the respondents] were as
children."
October 23, 2000
Q
"People seem angrier and
more rapidly frustrated than ever before...do you believe that most of
these people are depressed and/or that working Americans are becoming
increasingly depressed?"
A
One
in 10 office workers in Britain, the United States, Germany, Finland
and Poland suffers from depression, anxiety, stress or burnout, the
results of an International Labor Organization (ILO) survey show.
Information glut resulting from
technological advances, the pace of globalization, dysfunctional
office politics, overwork and job insecurity after a decade of
downsizing are the main contributors to workplace stress, the survey
found.
Depression is now the second most
disabling illness for workers after heart disease, according to the
survey.
Mental, neurological and behavioral
disorders are rising so fast that, if nothing is done, they will
outrank road accidents, AIDS and violence by 2020 as a primary cause
of work years lost from early death and disability, according to a
report released this week at a conference on despair at the workplace.
In pure business terms, depression
costs companies more than plant shutdowns or strikes, the ILO said,
calling the survey findings "a wake-up call for business."
Bad management costs companies not only in loss of productivity from a
less healthy and motivated workforce but also through higher staff
turnover with the associated costs of recruiting and training
replacement staff, the ILO pointed out.
Depression costs the United States $44
billion each year in direct costs for treatment of illness, lost
earnings and lower productivity at the workplace, and it costs 4% of
the European Union's Gross National Product, the survey found.
In the United States, clinical
depression has become one of the most common illnesses, affecting one
in ten working age adults at a cost of 200 million working days lost
each year, the survey said.
Mental health disorders are the leading
cause of disability pensions in Finland, where over 50% of the
workforce has some kind of stress-related symptom and 7% suffer from
severe burnout leading to exhaustion, cynicism and sleep disorders,
the ILO said.
In Germany, depressive disorders
accounted for almost 7% of premature retirements while
depression-related work incapacity lasts two and a half times longer
than incapacity due to other illnesses, the survey results showed.
.
October 16, 2000
Q
"If someone is traumatized...raped or assaulted in another
way...can this be passed along to the children?"
A
There is an important study
that bears upon your question. Second-generation
Holocaust survivors react with extreme psychological distress when
faced with a life-threatening illness such as cancer, according to
results of an Israeli study. Thus, the children Holocaust survivors
are themselves fragile.
Results of the Brief Symptom Inventory
showed the offspring of Holocaust survivors scored significantly
higher than the comparison group. The "grand severity index
score" was 66 for the survivors and 54 for the comparison group.
Scores on somatization, depression, anxiety, hostility, and
psychoticism were high enough to be considered in the range of
psychopathology.
These findings reinforce those of
previous studies in that vulnerability to affective and anxiety
disorders is transmitted to the offspring.
The investigators conclude, "The
fact that the traumatized parents were exposed over a long period to
uncontrollable and extreme situations could result in the transmission
of an intrusive-avoidant coping style to their children to such a
degree that it became in integral part of their personality."
Am J Psychiatry
2000;157:904-910.
October 9, 2000
Q
"Do people contact you first when they have problems or do they
tend to first tell their teachers or ministers?"
A
Twice as many people first turn to their primary care physician
for help with a mental health problem than to a psychologist. The
majority of people who experience symptoms of clinical depression or
generalized anxiety disorder (GAD) believe their primary care
physicians play a key role in helping them recover and maintain their
mental health and wellness.
In most cases, patients have seen their
primary care physician for years and have established a level of
comfort and trust with them. Thus, they want their family physician to
be more involved in detecting depression or GAD, and in helping them
recover.
Physicians can proactively screen for
depression or GAD at regular intervals, such as annual checkups,
intervene before a mental health problem worsens, and continue to
properly treat these illnesses.
Studies suggest that the prevalence of
major depressive disorders in the primary care setting is 5% to 10% in
the United States, with higher percentages seen in patients with
coexistent medical problems. In studies using self-reporting scales,
investigators have found evidence of depressive symptoms in 12% to 25%
of medical outpatients — a rate similar to that for acute upper
respiratory tract infections and hypertension. According to a World
Health Organization multicenter study of 15 international primary care
centers, 8% of patients suffer from generalized anxiety disorder
(GAD), making it the second most frequently occurring psychiatric
condition in primary care, after depression.
Patients who were aware of their
illness and who saw their primary care physician first had higher
recovery expectations.
Half of patients who saw their primary
care physician felt that a complete recovery (an absence of symptoms,
defined for this survey as mental wellness) from clinical depression
or generalized anxiety disorder (GAD) could be expected.
Generalized anxiety disorder (GAD), the
most common anxiety disorder, affects approximately 2.8% of the US
population (4 million Americans) each year. It is characterized by
overwhelming, chronic, and excessive worry, anxiety, and tension
persisting for at least 6 months. The pathological feature most
associated with GAD or long-term anxiety is excessive, pervasive, and
uncontrollable worry. Such worry is associated with a host of psychic
symptoms (e.g., concentration difficulties) and somatic symptoms (eg,
cold, clammy hands or sweating).
October 2, 2000
Q
"We have adopted a little boy who was sexually abused for several
years by his biological parents. He is a sweet child right now, but we
are concerned about possible emotional or behavioral risk factors as
he grows older."
A
Adolescents with a history
of sexual abuse are significantly more likely than their counterparts
to engage in sexual behavior that puts them at risk for HIV infection
Inconsistent condom use was three times
more likely among youths who had been sexually abused than among those
who had not. A history of sexual abuse was also significantly
associated with less impulse control and higher rates of sexually
transmitted diseases.
Abused children need adequate treatment
around abuse issues. Many re-experiencing the anxiety and trauma of
abuse for years. Most psychotherapy may not address current sexual
behavior and the anxieties that sexually abused adolescents
experience.
Am J Psychiatry
2000;157:1413-1415.
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