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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 19, 2005
Q "Do
people that are put on a respirator ever become depressed
being on it?"
A This
may be helpful: "Caregivers of patients who have
received prolonged mechanical ventilation may be at risk for
depression and poor physical health in the months following
hospital discharge.
The 8-week disease
management program, to which 211 of the caregivers were randomly assigned,
included emotional support from an advanced practice nurse through discussions,
referrals, and reassurance, as well as instrumental support through care
coordination, education and communication. There were at least eight
nurse-initiated contacts in the intervention group.
At the time of
patient's discharge from the hospital, 69.2% of caregivers in the control group
and 61.7% in the experimental group exhibited mild or no depression, based on
Center for Epidemiologic Studies depression scale (CES-D) scores.
Two months later,
61.2% of the experimental group and 53.5% of the control group had no more than
mild depression scores (p < 0.05). The experimental group also had a larger
percentage of caregivers who improved or stayed the same (55.6% versus 40.8%).
Thus, the
investigators note, "the intervention was, at the 2-month point, managing to
keep some caregivers from progressing to moderate or severe depression."
"The clinical
significance of the intervention," they add, "may be that empathetic listening,
support in planning and decision making, and referrals for support may have been
instrumental in minimizing depression in some caregivers.
The authors also
observed that 2-month CES-D scores were significantly higher among caregivers of
patients residing in an institution (15.5 versus 9.63, p = 0.00001). There were
also significantly worse outcomes for disrupted schedule, lack of family support
and health problems among those with institutionalized patients.
Dr. Douglas's team
posits that "some possible sources of their risk for depression could be the
more debilitated nature of institutionalized patients, possible guilt because
the patient is not being cared for at home, and possible frustration by
caregivers who have less control over their loved one's care in an institutional
setting." Chest 2005;128:3925-3936.
December 12, 2005
Q "How
much does stress play a role in diabetes?"
A
"Intensive, home-based psychotherapy can significantly
reduce diabetes-related stress in adolescents with type 1
diabetes...there are empirically-supported treatments that
have been shown to make a difference in improving both
psychosocial well-being, adherence, and health outcomes for
seriously non-adherent youth."
Researchers...investigated whether intensive, multisystemic
psychotherapy (MST) targeting family and other barriers to
good adherence would affect the adolescent's stress related
to diabetes and whether this would influence adherence and
metabolic control.
Adolescents who received MST experienced significantly
reduced levels of stress compared with those in the control
group... The intervention appeared equally effective for
younger and older, male and female, black and other
adolescents.
Diabetes stress was related significantly to metabolic
control both at baseline and after treatment, the results
indicate, but there was no association with age or
ethnicity.
Structural equation modeling indicated that the MST
intervention directly affected diabetic stress and
adherence, but there was no support for a specific effect of
stress on adherence."
Pediatrics 2005;116:e826-e832.
December 5, 2005
Q "My
wife has major depression, and I was wondering if they know
any more about why this happens in the brain."
A
"Results of a
functional MRI study demonstrate that several areas of the
brain associated with reward processing respond differently
to stimulation in patients with major depressive disorder (MDD).
Therefore, "the brain reward system may be an excellent
target for novel treatment approaches in drug development
research...The authors define the brain reward system as "a
neurobiological system that consists of extensive neural
pathways that mediate reward behaviors such as pleasure and
motivation." They theorize that this system "may represent a
key neuroanatomical substrate of anhedonia, a core symptom
of depression."
The investigators observed that, based on a standardized
test (the Addiction Research Center Inventory, ARCI), MDD
subjects had a hypersensitive, 2-fold increased response to
the rewarding effects of the drug (dextroamphetamine). There
was a positive correlation between ARCI scores and measures
of anhedonia.
MDD subjects exhibited significantly decreased activation
following dextroamphetamine administration in dopamine-rich
regions of the brain. Specifically, these involved the right
ventrolateral prefrontal cortex, the left and right caudate
and putamen, the left orbitofrontal cortex, and the
supplementary motor cortex and premotor cortex. Increased
activation was observed in the left and right temporal pole.
"Results of this study provide support for the involvement
of dopaminergic mechanisms in the altered reward processing
in MDD," Dr. Busto's group maintains.
Arch Gen Psychiatry 2005;62:1228-1236"
November 28, 2005
Q "Any
research on what makes a psychopath?"
A "A
variant in the catechol O-methyltransferase (COMT) gene and
birth weight are predictive of early-onset antisocial
behavior in children with attention-deficit/hyperactivity
disorder.
The researchers conducted a family-based genetic study from
1997 to 2003. Included were 240 children recruited from
child and adolescent psychiatric and child health clinics
who met the diagnostic criteria for
attention-deficit/hyperactivity disorder or hyperkinetic
disorder.
Specifically, mean conduct disorder scores were higher in
those with the val/val genotype and those with birthweight
lower than 2500 g. The association was independent of the
effects of age, sex, verbal IQ, and performance IQ.
The results of this study have potentially important
implications insofar as they suggest that among those with
ADHD who are at high risk of early-onset antisocial
behavior, possession of a specific risk genotype, the COMT
gene variant val/val genotype, not only predicts antisocial
behavior in itself but also increases susceptibility to the
effects of prenatal risk as indexed by birth weight.
Arch Gen Psychiatry 2005;62:1275-1278.
November 21, 2005
Q "I
have been on Zoloft for two years, and I read that this may
cause me to get breast cancer. Is that definitely true?"
A
"It was reported that clinically relevant doses of [fluoxetine]
accelerated the growth of mammary tumors in rodents.Contrary
to findings in rodent studies, the use of selective
serotonin reuptake inhibitors (SSRIs) does not appear to
increase the risk of breast cancer. Physicians can feel
confident that the evidence has accumulated that use of
SSRIs for 4 to 5 years does not increase the risk of breast
cancer.
Regular use of SSRIs was not associated with breast cancer
risk after adjustment for other risk factors, with an odds
ratio of 1.1, which wasn't significant, the investigators
report.
The odds ratios were not significantly different for women
who recently used SSRIs and for women who had stopped taking
SSRIs at least a year prior to their interview. Moreover,
all odds ratios were similar for pre- and post-menopausal
women, the results indicate.
These findings provide assurance that use of SSRIs for
durations of 4-5 years does not increase the risk of breast
cancer. However, these results do not address the risk of
taking these drugs continually for decades."
Am J Epidemiol 2005;182:835-838.
November 14, 2005
Q "My
sister's son has cancer. It is very tragic, and she seems to
be having a particularly rough time with it
naturally...anything special which we should look for?"
A
You may find this helpful: "Most parents of children
undergoing cancer treatment report posttraumatic stress
disorder (PTSD) symptoms...Symptoms of PTSD have been
reported in parents of children who have completed treatment
for cancer...More than two thirds of the mothers and 57% of
the fathers had PTSD within the moderate-to-severe range,
the results indicate. In families in which both parents
participated in the survey, 79.2% had at least one parent
with moderate-to-severe PTSD.
Only rarely did both parents report severe symptoms, and it
was uncommon for both parents to report mild PTSD.
Treatment intensity was not associated with distress level
for mothers or fathers, the researchers note, but there was
a low-magnitude negative association between the length of
time since their child's diagnosis and the level of PTSD...(the
symptoms may be) part of the process of responding and
reacting to one's circumstances and may be adaptive in
certain ways."
Knowledge and attention to PTSD symptoms can lead to more
appropriate multidisciplinary care of the patient and
family.
Early identification of at-risk families may promote the
development and evaluation of effective brief treatments. By
helping caregivers address their own psychological
well-being, we may be best assuring that the psychological
needs of the patients are also met.
Brief and
efficacious treatments have been developed to assist parents in adjusting to
their child's diagnosis and treatment, and effective psychological treatments
for posttraumatic disorders have been developed.."
J Clin Oncol 2005;23:7405-7410,7375-7377.
November 7, 2005
Q "I
want to quit smoking but know that the patch contains
nicotine which causes cancer...therefore, I do not know how
to quit..."
A "Quoting
a recent study "Many smokers think that nicotine causes
cancer, and that fear can significantly interfere with
efforts to stop...the majority of smokers - 71.9% of women
and 59.4% of men - believed that nicotine causes cancer. In
addition, 75% of women and 64.5% of men expressed worry that
smoking would give them cancer, and 71.9% of women and 63.1%
of men smoked "light" cigarettes, thinking this would lower
intake of nicotine and thus lower their risk of cancer.
...Nicotine does not cause cancer, but that is why patients
are reluctant to use patches to help them quit...It's the
delivery system that carries the risk...It's the cigarette
smoke that contains carcinogens, neurotoxins and other
toxins.
More women expressed
fear, guilt and worry about the risks they were taking with smoking (77.2%
versus 61.7% of men). They were also more afraid of failure in their attempts to
quit than men (17.5% versus 10.7%). However, quit rates at 30 days were
essentially the same for women and men (59.1% versus 54.9%).
Nicotine is the drug that smokers crave. That's why the patches are a good
alternative for those who want to quit...Smokers need a comprehensive care
program that includes pharmacotherapy using nicotine patches...
Complete abstinence is not used, because going "cold turkey" has a very high
failure rate...A program that involves behavior modification, guided imagery and
support systems are helpful," she concluded, "and patches are a very useful tool
in the program."
October 31, 2005
Q "Stress
seems to have a big role in health...is there any other
interesting research about stress?..."
A
"A short period of stress
in early life can lead to impaired learning and memory and a
decline in related cognitive abilities, results of animal
study indicate...psychological early-life stress in rats
causes a deterioration of the hippocampus that progresses
from young adulthood to middle age.
The researchers elicited early-life stress in rats by
limiting the nesting material in cages where they lived with
their mothers. This led to emotional stress (enlarged
adrenals, increased corticosterone levels, and modest weight
loss) in both mothers and pups. All signs of this stress
disappeared by the time the rats reached adulthood...
Starting in middle age, the rats that endured early-life
stress began to exhibit deficits in their ability to
remember the location of objects they had seen before. They
also had trouble recognizing objects that they had
encountered on the previous day. These difficulties worsened
as the rats grew older, and developed much more rapidly than
in rats that were raised from the first week of life in a
typical nurturing environment.
...cellular bases for the cognitive difficulties were a
result of change in the fine structure of brain cells, which
impaired their ability to enhance their communication, as
normally happens during the process of learning...
facilitated communication is known as long-term potentiation."
...over 50% of the world's children are raised under
stressful conditions. While it has been suspected that early
life stresses can lead to later cognitive impairment, it is
not possible to affirm this suspicion in human studies,
because the genetic background of children or other
confounders make these analyses too complex...
J Neurosci
2005;25:9328-9338.
October 24, 2005
Q "Can
psychological factors effect things like cancer?"
A recent article indicates
that: "Ovarian cancer patients with greater social support
have stronger natural killer (NK) cell activity in
tumor-infiltrating lymphocytes as well as peripheral blood
mononuclear cells...a link between psychosocial factors and
immune function in cells isolated from human tumors....the
researchers compared NK cell cytotoxicity (NKCC) in
peripheral blood, TIL and ascites in 42 patients with
ovarian cancer. Twenty-three patients with suspected ovarian
cancer later found to be benign served as a control group.
In peripheral blood, the researchers found, NKCC was lower
in the ovarian cancer patients than in the women with benign
masses. Ovarian cancer patients had lower NKCC activity in
TIL compared to PBMC and ascites.
However, after adjustment for cancer stage, stronger social
support was related to higher NKCC in TIL and PBMC, while
higher distress was tied to lower NKCC in TIL. Multivariate
analysis found the effects of social support and distress
were independent.Psychosocial factors were most strongly
tied to NKCC in TIL, which is "noteworthy...the sympathetic
nervous system serves as a direct link between the ovary and
the central nervous system, while the acidic environment of
the ovary may help preserve catecholamines.
The magnitude of relationships between social support,
distress and NKCC, particularly in TIL, was quite large and
suggests that psychosocial factors may contribute to the
robustness of the innate immune response in the tumor
microenvironment..."
J Clin Oncol 2005;23:7105-7113.
October 17, 2005
Q "I
gather that sometime schizophrenia is not recognized for
awhile in some families. Does this result in the person
taking longer to get better?"
A A recent article indicates: "The greater the
interval between the onset of psychosis and its treatment,
the greater the severity of negative symptoms...On average,
there is a delay of over a year -- or longer -- from the
time that the symptoms of schizophrenia first emerge to the
time that the person first receives treatment...the sooner
treatment is started, the better the clinical and functional
outcome...A shorter duration of untreated psychosis was
associated with greater response to antipsychotic treatment.
This was manifested by improvement in severity of global
psychopathology in 5 studies, positive symptom severity in
13 studies and negative symptom severity in 14 studies.
Thus, ameliorating the symptoms of the initial psychosis may
not only lessen the immediate suffering and burden of
disease experienced by patients and their families, but may
also improve long-term prognosis by limiting progression of
the illness and preserving a person's ability to respond to
antipsychotic medication.
Intervention
programs that are effective in reducing the length of the initial psychotic
episode," she concluded, "may enhance the likelihood of recovery from a first
episode of schizophrenia."
Am J Psychiatry 2005;162:1785-1804.
October 10, 2005
Q
"Can stress cause a child
to become diabetic?"
A You will may be interested in
this: "Mothers' psychological stress, measured as exposure to negative life
events, seems to be involved in the onset or progression of diabetes-related
beta-cell destruction in young children...mothers' experience of divorce or
violence raised the risk of diabetes-related autoimmunity in children at age 2.5
years by roughly threefold....this could be explained by increased cortisol
concentrations leading to insulin resistance, which in turn may stress the
insulin-producing beta cells and thereby trigger a diabetes-related autoimmune
reaction in genetically predisposed children...the associations between
psychological stress and autoimmunity were not likely to be explained by any of
the known risk factors for type 1 diabetes analyzed: type 1 diabetes in the
family or extended family, increased parental age, childhood infections, body
weight of the child, delivery by caesarean section, and the need for neonatal
intensive care...conclude that psychological stress could be a risk factor for
the development of type 1 diabetes, since it appears to be one trigger mechanism
behind diabetes-related autoimmunity early in life...it is important to reduce
negative stress in children and this issue needs priority especially among
clinicians working with children. It is central to look at the whole family
situation and to try to reduce parenting stress, by for example discussing
various coping strategies in connection with serious life events."
Diabetes Care 2005;28:2394-2399.
October 3, 2005
Q "Our
daughter is bulimic and also seems to be having panic
attacks. This does not seem logical to us, and we wonder if
it is medication she is taking."
A
While medication is always
a consideration, please note: "The results of a study
support shared transmission of eating disorders and anxiety
disorders in adolescent girls.
The investigators observed significant comorbidity between
eating disorders and major depression, anxiety disorders,
and nicotine dependence.
These results suggest that eating disorders and anxiety
disorders share familial risk factors.
The next step would be to examine whether the shared
transmission is explained by genetic or environmental
factors or a combination of both.
The participants in the study were young (and) it is likely
that some of the participants who did not have mood
disorders or substance use disorders may develop these
problems in the future. As participants move through the
period of risk for developing different kinds of mental
disorders, we might find evidence of shared transmission
between eating disorders and other types of mental
disorders.
Int J Eat Disord 2005;38:99-105.
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