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Clinical
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Atlanta Medical
Psychology
The clinical
practice of Dr. David B. Adams is located in The Medical Quarters in
the northside of Atlanta at the junction of Scottish Rite, Northside
and Saint Joseph's Hospitals. Dr. Adams consults to occupational
medicine, surgeons, nurse case managers, insurers and employers
regarding the psychological impact of work-related injury and the
role of psychological factors in short- and long-term
disability. |
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| PAST QUESTIONS OF THE WEEK |
December 29, 2003
Q "My
mother had a stroke about six years ago. She came through it fine with no
problems afterwards. She is only 67 years old, but they think she is showing
signs of Alzheimer's Disease. Did the stroke cause that?"
A You
may find this a helpful starting point. "Stroke is associated with an
increased risk of Alzheimer's disease (AD) in the elderly population. The
researchers documented history of stroke and presence of cardiovascular risk
factors at baseline in 1992, and calculated incidence rates for AD during
followup through 1999. Proportional hazards ratios for AD among subjects
with and without a history of stroke were computed using age at onset of AD
as the time-to-event variable.
The annual incidence for AD was 5.2% for patients with stroke had an,
compared with 4% among those without stroke. The hazard ratio for AD was 1.6
for those with a stroke history relative to those without.
Of the vascular risk factors (hypertension, diabetes, and heart disease),
the team found that only diabetes was related to the risk of AD independent
of stroke history
The association between stroke and AD might be explained by a common
vascular disease process.
Arch Neurol 2003;60:1707-1712.
December 22, 2003
Q "If you
have a parent with Alzheimer's Disease and you worry about it, will you be
more likely to get it?"
A Well,
not exactly, but there does appear to be a stress related component to the
disease. You may be interested in this:
"Susceptibility
to psychological distress seems to be associated with the risk of
Alzheimer's Disease. It is possible that antidepressants or other drugs
could attenuate the effects of stressful experience on brain structure and
function.
Because chronic stressful experience is linked to structural changes in the
hippocampus and with impaired learning and memory, it is hypothesized that
propensity to experience psychological distress is related to risk of
Alzheimer's Disease.
Episodic memory, which is primarily mediated by hippocampal formation, was
more affected by neuroticism scores than were other cognitive systems, such
as semantic memory and visuospatial ability.
Distress-proneness predicts an increased risk of clinical AD in an elderly
population.
Neurology
2003;61:1479-1485.
December 15, 2003
Q "Why do
men die soon after the death of their wife?"
A There
are a number of explanations, but one of the most interesting is the
controversy over the relationship between depressive symptoms and cardiac
events in patients with stable coronary artery disease (CAD). Some urge the
treatment of depression in medically ill patients. Others note that
depression is not the cause of fatal cardiac events.
Multiple studies have described strong associations between depression after
acute heart disease and subsequent morbidity and mortality. However, many of
these studies were conducted during the acute stage of a cardiac event.
The authors observed no association between depressive symptoms and
cardiovascular mortality after adjusting for age, gender and location. There
was a modest association with nonfatal cardiovascular events, the report
indicates, and a strong association between depressive symptoms and dyspnea,
angina, and claudication (nonfatal events).
After adjustment for cardiovascular risk factors, socioeconomic variables
and symptoms of CAD, there was no evidence of an association between
depressive symptoms and prognosis, they say.
But even if a causal link between depression and cardiac prognosis cannot be
established, depression in medically ill patients should not be ignored.
Moreover, depression directly affects many of the variables studied, and, as
a result, their analysis "may have hidden the true effect of depression."
Regardless, treatment for depression is important in and of itself, because
depression causes "tremendous decreases in quality of life and functional
impairment in any group of patients with chronic illness...Treating
depression makes a huge difference in quality of life and function."
Eur Heart J 2003;24:2027-2037.
December 8, 2003
Q "My
sister's child, my niece, has been told that she is a carrier of cystic
fibrosis. I have not spoken to my sister, but I would imagine that she is
very upset. How should I approach this?"
A A recent article
found that: "Identification of a healthy infant as a carrier of a cystic
fibrosis mutation does not overly distress parents. The biggest hurdle these
parents face appears to be the need to discuss the findings with family
members.
Screening for cystic fibrosis is recommended for newborns in the United
Kingdom. Some professionals oppose this policy, because of the potential
stigma and the possibility that identification of healthy carriers of the CF
mutation will affect the mother/child relationship.
Parents were in favor of newborn screening and appreciated knowing their
offspring's carrier status. There seemed to be no change in parent/child
relationships, and parents were no more likely to become overly anxious,
overprotective, or rejecting of their baby.
Health care professionals should be careful to not unduly scare parents when
notifying them of initial screening results. For example, they should not go
into depth about the disease itself, and they should reassure parents that
not all carriers have the disease.
Parents were also concerned about having to discuss the new knowledge with
their extended family. The authors recommend that the index family be
assisted in this effort, and that they be given written information about
the condition and the purpose of cascade screening to pass on to other
family members."
Arch Dis Child Fetal Neonatal Ed 2003;88:F467-F471.
December 1, 2003
Q "Is
there any way to predict whether my memory will fade with age or what can be
done?"
A Physical
exercise and mental stimulation can effect the rare of memory loss in many
individuals. There is also a study that reports: "The rate of medial
temporal lobe (MTL) atrophy on magnetic resonance imaging (MRI) is
associated with cognitive decline.
The best predictor of cognitive decline was MTL atrophy, based on an
automated procedure including spatial correlation of the baseline and
follow-up images and regional boundary shift analysis. Overall accuracy was
89% (in 40 of 45 subjects); specificity was 91% (in 29 of 32 subjects), and
sensitivity was 85% (in 11 of 13 subjects).
The rate of decline from mild cognitive impairment to dementia is 10% to 15%
each year, compared with a rate of 1% to 2% in healthy elderly, according to
the study. Early detection of subjects likely to develop cognitive
impairment could facilitate earlier diagnosis and therapeutic intervention."
Radiology. 2003;229:691-696
November 24, 2003
Q "I
suffer from repeated bouts of depression. I take medicine for this. Does
this medicine damage my brain?"
A Actually,
the greater risk may be from recurrent depression, and you are wise to
follow your doctor's advice in taking your medication. There is a
recent article which found:
"In women with
recurrent major depressive disorder, prolonged depression is associated with
a loss of global cerebral gray matter volume.
Previous postmortem and neuroimaging studies have yielded inconsistent
associations between recurrent depression and brain volumes, the authors
explain, with some showing hippocampal losses and others showing
abnormalities in other brain regions.
After correcting for intracranial volume, depression duration correlated
negatively with total cerebral gray matter, frontal gray matter, temporal
gray matter, and parietal gray matter. The association between depression
duration and gray matter losses remained after adjustments for age and
intracranial volume, the report indicates. Depression duration did not
correlate with any other magnetic resonance imaging (MRI) data.
Effects of medication need to be ruled out, but it is important to improve
early diagnoses and to start therapeutic interventions early in order to
limit the duration of the depressive episode." Am J Psychiatry
2003;160:2052-2054.
November 17, 2003
Q "Is
there a psychological cure for arthritis?"
A No, but "Improved
primary care treatment of depression for the elderly not only reduces
depressive symptoms but reduces arthritis pain and improves quality of life.
Current medical treatments cannot cure osteoarthritis nor eliminate
arthritis-related pain and disability entirely. Arthritis management needs
to be aimed at decreasing pain, improving function, and enhancing quality of
life. In the elderly, both depression and arthritis are common causes of
disability and medical and economic costs. The prevalence of depression is
about 16%, whereas osteoarthritis is the most common type of arthritis in
older adults, affecting about one third of individuals older than 65 years
and almost 80% of those older than 70 years.
Benefits from increased recognition and improved treatment of depression in
patients with comorbid arthritis and depression extended beyond reduced
depressive symptoms to include improved pain and functional outcomes.
Recognition and treatment of depression has the potential to lessen the
public health burden of comorbid arthritis and late-life depression."
JAMA. 2003;290:2428-2434
November 10, 2003
Q "My
wife has been depressed since the birth of our son 8 months ago. I am
concerned about her, but I am also concerned with the impact that this may
have upon him?"
A You
may want to research this area, but here is a start:
"Eleven year-olds whose mothers were depressed after giving birth are more
likely to exhibit violent behaviors than children of mothers who didn't
experience postpartum depression, new research indicates.
These findings suggest that postpartum depression may serve as a warning
sign their children are at risk of long-lasting problems...whether the
mother's depression causes the violence...What we do know is that the
mother's depression is a reliable sign that children will have problems
later on, and, for some children, that will include the risk of violence.
While most children were not violent, children of mothers who were depressed
3 months after giving birth were more likely to exhibit violent behaviors,
particularly if depression recurred. Violent behaviors included fighting at
school and using weapons during fights.
Although boys tended to be more violent, girls of mothers with postpartum
depression were also at risk. Indeed, one mother described her daughter as
"out for the kill."
Infants raised by depressed mothers may be more at risk of later violence
because they are less able to manage their emotions, including anger.
Previous research has shown that depressed mothers are less able to focus on
infants, or speak to them in a manner that helps them calm themselves.
Infants with depressed mothers may not learn how to quell their own
agitation."
Dev Psychol 2003;39:1083-1094.
November 3, 2003 Q "Smoking is a disgusting behavior. It smells bad, looks bad, is unhealthy...aside from lung cancer and heart disease and birth defects is (sic) there other problems it can cause?" A You may want to find a summary of an article in the October 28, 2003, issue of Neurology. It is reported that smokers are up to three times more likely to develop multiple sclerosis than nonsmokers, researchers report in the
The researchers found that most of the 87 people in the study who had multiple sclerosis started smoking 15 years before they developed the disease. Of the multiple sclerosis patients, nearly 24% had never smoked and about 76% were current or past smokers. It was not clear why male smokers had a higher rate of MS than women. The disease is not caused by smoking, but risk co-factors that may be increased by smoking. October 27, 2003 Q "They tell us our son is bipolar and only medication will help him and us...are there other treatments we should consider?" A Quoting from a recent presentation: "Cognitive behavioral therapy (CBT) is useful for the treatment of bipolar disorder in children. Child and Family Focused Cognitive Behavioral Therapy (CFF-CBT) is a new, developmentally sensitive psychosocial intervention for pediatric bipolar disorder (PBD) and is intended for use along with medication. Its theoretical basis includes the need to address problems specific to pediatric bipolar disorder, a biological theory of excessive reactivity, and environmental stressors. Over 12 sessions, CFF-CBT actively involves children, their parents, and siblings. After completion of therapy, patients had significant reductions in severity scores on all CGI-BP scales, suggesting improvement in mania, depression, aggression, attention deficit-hyeractivity disorder, and sleep disorder, and, to a lesser extent, psychosis. The strengths of this treatment include its applicability to both children and adolescents, flexible timing allowing a two- to four-week gap between sessions, a checklist covering pertinent points for practitioners, therapy for parents helping them react appropriately to explosive behavior, and involvement of siblings." October 20, 2003 Q "I am a high school teacher and several of our seniors are on anti-depressants. We had a recent suicide in a senior boy. What is some of the current thinking about antidepressants and suicides in this age group?" A This is from a recent internal medicine article which may be helpful: "...a fall in adolescent suicide rates in the US has coincided with an increase in antidepressant use. Now, new study findings strengthen this association by showing that these changes often occurred in the same geographical regions. Overall, a 1% increase in adolescent use of antidepressants was accompanied by a drop of 0.23 suicides per 100,000 adolescents per year. Previous reports have shown that younger adolescents are less likely than older ones to have a diagnosable disorder. Therefore, these younger patients are less likely to have a disorder that is known to respond to antidepressants, he added. The increased availability of antidepressants that occurred in the last decade may have had more opportunity to help adolescents from lower rather than higher income families. Females have a higher ratio of suicide attempts to suicide completion. The higher case fatality ratio in boys may mean that they benefit more from antidepressant therapy.
Arch Intern Med 2003;60:978-982. October 13, 2003 Q "How common is the fear of public speaking? I am a wreck when I talk before a group at work." A Approximately 11% of all visits to primary care physicians are prompted by anxiety and nervousness,ourth to fifth year of follow-up. Mean age of onset of social anxiety disorder was 14 years, Dr. Maki reported, indicating an earlier onset than for other anxiety disorders. Social anxiety disorder has a chronic, unremitting course, with a pervasive detrimental impact. Comorbidities were common in the group, with major depressive disorder the most common. A history of suicide attempts was found in 16% of the patients, which is four times higher than the rate in the general population. For patients with social anxiety disorder and major depressive disorder, suicide attempts were six times that of the general population. There is a lifetime prevalence of 13% for social anxiety disorder. It is the third most common disorder, after depression and substance abuse. October 6, 2003 Q "My wife's sister is getting breast implants. We have heard that these cause suicide, but she will not listen to us. A "Results of a study in the October Annals of Plastic Surgery suggest that women who undergo cosmetic breast implantation are at increased risk for suicide. Deaths due to suicide were most pronounced in the first 5 years of follow-up.
They emphasize, however, that the study does not prove a cause-and-effect relationship between cosmetic breast implants and suicide. It may have more to do with the type of women that choose cosmetic breast implantation. It is also noteworthy, that "the Finnish and Swedish populations have a higher incidence of suicide in general.""
Ann Plastic Surg 2003;51:339-345.
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