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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 |
March 21, 2005
Q "I
have not a clue as to what child birth feels like, but my
wife carries on like there's no tomorrow and then is
depressed for months after the birth of each child. Now she
is pregnant again. Are there some studies in this area?
A
"Women who catastrophize labor pain -- that is, they have an
exaggerated negative orientation to pain -- are likely to
adjust less readily to the demands of motherhood and are
more prone to postpartum depression. Pain catastrophizing
includes three components: focus on pain, exaggeration of
the consequences of pain, and experience of helplessness.
After adjusting for maternal age and education, parity, and
type of analgesia, pain catastrophizing during labor --
rather than pain intensity -- significantly predicted
maternity blues and postpartum social functioning. Younger
and less educated women also had a higher risk of depression
and impaired social functioning.
These findings suggest that before analgesia is given, pain
catastrophizing should be addressed." Am J Obstet Gynecol
2005;192:826-831.
March 21, 2005
Q "My
daughter has just completed a program for her eating
disorder. I think she is finally cured after five years.
Should she also see her doctor for problems caused by the
eating disorder...she has no symptoms?"
A
Yes, please read this: "Community-dwelling women with
anorexia nervosa have a high prevalence of medical findings
including metabolic, hematologic, hemodynamic and skeletal
abnormalities. The findings underscore the importance of
medical evaluation of patients with anorexia nervosa along
with psychological treatment.
Less than 15% of the
women had normal bone densities, while 38.6% were anemic, 34.4% had
leukocytopenia and 41.3% had bradycardia. Hyponatrenemia and hypokalemia were
each seen in 19.7% of the women, while low potassium - known to be associated
with purging - was seen even among women who denied purging behavior. This may
have been because the women were reluctant to admit to purging, the researchers
note, but an association between low weight and hypokalemia cannot be ruled out.
"Even if a woman with anorexia nervosa denies purging, a potassium level is
really important and indicated...hypokalemia can lead to potentially deadly
heart arrhythmias. Other abnormalities included hypotension in 16.1% of
patients, hypothermia in 22.4%, and elevation of alanine aminotransferases in
12.2%.
Physicians should
consider a diagnosis of anorexia nervosa in women of low weight who have these
abnormalities, as many has half of cases of anorexia nervosa go undiagnosed in
the medical setting. Conversely, the absence of such abnormalities should not
rule out the possibility of the disorder.
Testing for
abnormalities other than hypokalemia may be controversial because most cannot be
treated medically except by reversal of the condition. Nevertheless, discussing
these abnormalities with an anorexia nervosa patient can help with the denial
common among those with the disorder,"
Arch Intern Med 2005;165:561-566.
March 14, 2005
Q "Any
recent studies on depression in the elderly?"
A
"About one in five elderly
Medicaid recipients diagnosed with depression receives
neither psychotherapy nor a prescription for
antidepressants, a new study shows.
Past research suggests depression is undiagnosed and
untreated more often in older adults and there is evidence
that the problem is worse in elderly African-Americans, the
researchers note. African Americans may also be more likely
to be prescribed tricyclic antidepressants than selective
serotonin reuptake inhibitors (SSRIs). The disparity also
was seen among patients in nursing homes, for whom patient
preferences in determining treatment would be less of a
factor. He and his colleagues are currently looking into
this issue in more detail."
J Am Geriatr Soc 2005;53:456-461
March 7, 2005
Q "Is
there anything new in the management of chronic pain in
children?"
A
I found this to be interesting
and so may you:
"Virtual reality (VR) games can be used to manage acute
pain in children.
Intervention with VR games is based on distraction or
interruption in the way current thoughts, including pain,
are processed by the brain. Research on adults supports the
hypothesis that VR has a positive influence on burn pain
modulation.
The (current) study provides strong evidence supporting VR-based
games in providing analgesia with minimal side effects and
little impact on the physical hospital environment, as well
as its reusability and versatility.
There appears to be considerable scope for further research
into the potential for using VR in the clinical setting. The
next stage would be to test VR alone against pharmacological
pain relief, to investigate whether VR is as effective in
isolation, and could decrease use of analgesia, thus
avoiding the side effects associated with medication."
BMC Pediatr. 2005;4:27
February 28, 2005
Q "Is
it not true that if a woman has a C-section that she will
more likely become depressed after delivery?"
A
"Having a cesarean section or assisted vaginal delivery does
not alter the risk of postnatal depression compared with an
unassisted vaginal birth, new prospective study results
suggest.
Thus, "there is no reason for women with a history of
depression or those at high risk of depression to be managed
differently with regard to mode of delivery."
The rate of postnatal depression was not
significantly higher for those with an elective C-section compared with planned
vaginal delivery."
February 20, 2005
Q "If
anti-depressants cause (sic) suicide, should anyone be
taking them?"
A "The findings from two reviews of
trial data suggest that it would be premature to conclude that selective
serotonin reuptake inhibitor (SSRI) use does not have some effect on suicide
risk. Moreover, results from a case-control study support a weak link between
SSRI use and self harm among pediatric users.
Among adults, there was no evidence that SSRI use raised the risk of suicide or
non-fatal self-harm to a greater extent than tricyclic antidepressants. In
children and adolescents, by contrast, SSRI use increased the risk of non-fatal
self-harm by 59%. No suicides were observed in this younger age group.
In adults, clinicians "need to balance the benefits and harms" of prescribing
SSRIs. By contrast, in children and adolescents, the risks generally outweigh
the benefits and such drugs should not be prescribed on a routine basis."
BMJ 2005;330:373-374,385-393,396-399.
February 13, 2005
Q "I
continue to read where antidepressants cause murder and
suicide...why should any of us risk taking them?"
A "Suicide rates have dropped in
association with increased use of selective serotonin reuptake inhibitors (SSRI)
and new-generation non-SSRIs.
Approximately 30,000 people die annually by suicide in the US. Although 60% of
suicides occur during a mood disorder, mostly untreated, little is known about
the relationship between antidepressant medication use and the rate of suicide
in the US.
Using data from all US individuals who committed suicide between 1996 and 1998,
the investigators extracted national county-level suicide rate data broken down
by age, sex, income, and race. They also determined national county-level
antidepressant prescription data, expressed as the number of pills prescribed.
The main outcome was the suicide rate in each county expressed as the number of
suicides for a given population size.
After adjustment for age, sex, race, income, and county-to-county variability in
suicide rates, antidepressant medication prescription was not significantly
related to suicide rate. However, within individual classes of antidepressants,
prescriptions for SSRIs and other new-generation non-SSRI antidepressants, such
as nefazodone hydrochloride, mirtazapine, bupropion hydrochloride, and
venlafaxine hydrochloride, were associated with lower suicide rates, both within
and among counties. There was a positive association between tricyclic
antidepressant (TCA) prescription and suicide rate. In rural areas, higher
suicide rates were associated with fewer antidepressant prescriptions, lower
income, and relatively more prescriptions for TCAs.
A high number of TCA prescriptions may be a marker for those counties with more
limited access to quality mental health care and inadequate treatment and
detection of depression, which in turn lead to increased suicide rates. By
contrast, increases in prescriptions for SSRIs and other new-generation non-SSRIs
are associated with lower suicide rates both between and within counties over
time and may reflect antidepressant efficacy, compliance, a better quality of
mental health care, and low toxicity in the event of a suicide attempt by
overdose.
Arch Gen Psychiatry. 2005;62:165-172
January 31, 2005
Q "My
son has many symptoms of depression, and his doctor told him
that he believes him to be depressed. My son appears to be
unwilling to day anything about it. Is that common?"
A "Negative beliefs and attitudes
strongly increase the likelihood that a young adult will refuse treatment for
depression.
"After adjusting for severity of illness, a patient's attitudes, fear of stigma,
and past treatment experiences explain about 85% of the reason why people don't
want to accept treatment."
Fewer than half of young adults seek treatment during an episode of depression.
Previous investigations have placed the onus for this finding on physicians and
the health care system.
Twenty-six percent of the subjected stated they intended not to accept a
physician's diagnosis of depression.
Regression analysis showed that negative beliefs about the biological basis of
depression and disagreement that medications are effective were significant
predictors of not accepting a diagnosis of depression.
Likewise, embarrassment regarding friends knowing about their depression and
fear that their family would be disappointed also significantly affected
subjects' openness to a diagnosis, as did previous experiences with treatment."
Ann Fam Med 2005;3:38-45.
January 24, 2005
Q "My
wife has a glass of wine...a large glass every evening. I
tell her that this is going to cause heart disease and
Alzheimer's Disease. Please provide information that
supports my belief."
A "Moderate alcohol consumption does
not impair cognitive function and may decrease the risk of decline. The adverse
effects of excess alcohol intake on cognitive function are well established, but
the effect of moderate consumption is uncertain. A cognitive benefit from
moderate alcohol intake is plausible, given the strong link between moderate
alcohol intake and the decreased risk of cardiovascular disease."
Moderate drinking was defined as consumption of 1.0 to 14.9 g of alcohol, or
about one drink, per day. Cognitive impairment was defined as the lowest 10% of
the scores, and a substantial decline in cognitive function over time was
defined as a change that was in the worst 10% of the distribution of the
decline.
After multivariate adjustment, moderate drinkers had better mean cognitive
scores than nondrinkers. This pattern persisted for cognitive decline. On a test
of general cognition, the relative risk of a substantial decline in performance
over a two-year period was 0.85 for moderate drinkers compared with nondrinkers.
Higher levels of drinking (15.0 - 30.0 g/day) were not significantly correlated
with the risk of cognitive impairment or decline. Data suggest that in
women, up to one drink per day does not impair cognitive function and may
actually decrease the risk of cognitive decline. Persons seeking to maximize
cognition in old age must keep in mind both the uncertainty of the current
results and the knowledge that alcohol consumption can be a double-edged sword,
with the dangers of overindulgence being all too familiar."
N Engl J Med. 2005;352:245-253, 289-290
January 17, 2005
Q "My
husband and I both need mental health care. However, when
our managed care company sends us for help, all we are
offered are drugs. What's up with that...we need more."
A Read this: More Americans than ever
are being treated for substance abuse, depression, and other mental health
disorders, but the treatment they are getting is increasingly limited to
prescription drugs alone.
That is the finding from a government study that assessed changing patterns in
the treatment of mental illnesses from the mid-1990s to 2001. While the number
of people receiving other types of treatment, such as psychotherapy or
behavioral therapy, remained the same during the five-year evaluation period,
prescription drug use increased rapidly.
Mental Health Drug Costs Rose 20% a Year
80% of the growth in mental health expenditures can be explained by the increase
in the use of selective serotonin reuptake inhibitors (SSRIs) and other
antidepressants, and high-priced schizophrenia drugs called "atypical
antipsychotics.
Prozac is credited with bringing drug treatment for mental health disorders to
the masses. It was the first of the SSRIs, but is now prescribed less often than
newer, and more expensive, SSRI and non-SSRI antidepressants
Probably no more
than half of the people with mental disorders get any kind of care, and about
half of those who do get care obtain it through their primary care doctor, which
means they are probably getting drugs alone.
Studies show that
drug treatment is as effective as other treatments for depression and many other
types of mental illnesses. For some disorders, such as schizophrenia, combining
drugs with psychotherapy is usually more effective than drug therapy alone."
January 10, 2005
Q "Our
son was born in the 30th week of my pregnancy. He seems
fine. What learning problems occur with premature
birth?"
A Your pediatrician can assist you in
determining if there is any cause for concern. The following article refers to
children born significantly younger, but it may be of interest: "Cognitive
impairment is common at school age for children born extremely premature. Birth
before 26 weeks of gestation is associated with a high prevalence of neurologic
and developmental disabilities in the infant during the first two years of life.
The high prevalence of disability at 30 months of age made it important to
assess this cohort further, at a later age, when the degree of disability can be
more clearly defined and is more likely to be predictive of problems that will
continue throughout childhood and into later life.
Using test reference norms, 21% of the children born extremely preterm had
cognitive impairment, defined as results more than 2 standard deviations below
the mean, compared with 1% of the standardized data. When compared with their
classmates, however, 41% of the extremely preterm group had cognitive
impairment. Disability was severe in 22%, moderate in 24%, and mild in 34%, and
30 children (12%) had disabling cerebral palsy.
Of those children who had severe disability at 30 months of age, 86% still had
moderate-to-severe disability at six years of age. However, other disabilities
at age 30 months were poor predictors of developmental problems at six years of
age.
The proportion of children with no disability in the current report (20%)
suggests the possibility of identifying biologic, environmental, and genetic
factors that provide protection to these vulnerable infants."
N Engl J Med. 2005;352:9-19,71-72
January 3, 2005
Q "My
wife is a very hostile woman...I love her, but she is almost
always angry. Her parents both died of heart attacks...won't
this increase her chances for that?"
A This supports some of your concerns "A
new analysis suggests the association between coronary heart disease (CHD) and
hostility could be due to certain physiological mechanisms as well as unhealthy
behaviors.
Even after adjustment for health behaviors, hostility increased the risk of
lipid metabolic disorder (LMD) in women with high or average familial CHD risk,
as well as men with high CHD risk.
Past research with the same cohort found a link between coronary disease
endpoints and hostility in men and women at high familial CHD risk, but not in
average-risk individuals.
The current finding of an association between hostility and LMD in average-risk
individuals as well was "unexpected"; neuroendocrine factors as well as
gene-environment interactions could be involved.
After adjustment for health behaviors, an association between hostility and LMD
and glucose level was seen in the high-risk women, while LMD alone was
associated with hostility in women at average risk.
In high-risk men, plasminogen activator inhibitor type 1 levels as well as LMD
were tied to hostility, while in average risk men an association was only seen
for fibrinogen levels.
Added to the accumulating data on the associations between hostility and
cardiovascular morbidity and mortality, these results indicate that further
investigation of mechanistic pathways is warranted."
Arch Intern Med 2004;164:2442-2448.
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